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TUMOURS 
INNOCENT    AND    MALIGNANT 


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TUMOURS 

INNOCENT    AND  MALIGNANT 

THEIR  CLINICAL   CHARACTERS  AND 
APPROPRIATE  TREATMENT 


BY 

Sir  John   BLAND-SUTTON,  F.R.G.S. 

Surgeon  to,  and  Member  of  the   Cancer   Investigation  Committee  of 
the    Middlesex  Hospital,  etc. 


WITH   THREE    HUNDRED    AND    SIXTY 
ILLUSTRATIONS 


FIFTH    EDITION 


NEW    YORK 
FUNK    AND    WAGNALLS    COMPANY 


PREFACE    TO    THE    FIFTH    EDITION 

Twenty  years  ago  our  knowledge  of  malignant  tumours 
was  unsatisfactory,  especially  in  relation  to  tlie  Cancer 
group.  The  description  of  cancer  (or  carcinoma)  was 
founded  on  a  study  of  this  disease  as  it  appears  in  the 
breast.  It  was  not  possible  to  write  a  satisfactory  account 
of  malignant  disease  occurring  in  organs  like  the  kidney, 
uterus,  thyroid  gland,  ovary  or  testicle.  The  clinical  features 
and  the  modes  of  death  not  only  vary  according  to  the  organ 
attacked,  but  are  modified  by  the  environment  of  the  can- 
cerous organ.  The  enterprises  of  suigeons  were  limited  until 
accurate  information  was  forthcoming  in  regard  to  these 
matters,  for  a  knowledge  of  the  pathology  of  malignant 
growths  is  of  prime  importance  to  those  engaged  in  the 
operative  treatment  of  these  diseases. 

Since  the  first  appearance  of  this  book  (1893)  a  large 
amount  of  investigation  has  been  carried  out  in  relation  to 
cancer  of  individual  organs.  The  frequency  with  which  it 
arises  in  the  gall-bladder  has  come  as  a  surprise  to  physi- 
cians as  well  as  to  surgeons.  Another  new  thing  is  the 
discovery  that  the  Fallopian  tube  is  liable  to  be  the  seat 
of  primary  cancer.  Among  more  recent  additions  to  our 
knowledge  of  cancer  is  the  recognition  of  the  fact  that 
cancer  of  the  ovary  is  due  to  implantation  of  cancerous 
particles  shed  from  a  primary  focus  in  the  breast,  the 
colon,  the  stomach,  or  the  gall-bladder,  or  poured  out  from 
the  open  mouth  of  a  cancerous  Fallopian  tube.  Informa- 
tion on  these  things,  as  well  as  much  new  matter  bearing 
on  the  cancer  problem,  is  incorporated  in  this  edition. 

47,  Brook  Street,  Grosvenor  Square,  W. 
January  1911. 


EXTRACT    FROM    THE    PREFACE    TO 
THE    FIRST    EDITION 

In  1885  I  began  to  collect  materials,  from  man  and  other 
vertebrates,  in  order  to  make  myself  acquainted  with  the 
histological  peculiarities  of  tumours.  Attention  was  first 
devoted  to  Cysts,  and  the  results  of  the  investigation  were 
embodied  in  lectures  delivered  at  the  Royal  College  of 
Surgeons  during  the  years  1886-91  :  they  dealt  particularly 
with  the  group  of  tumours  known  as  Dermoids  and 
Tubulo-Cysts.  During  the  same  period  I  contributed  to  the 
Odontological  Society  of  Great  Britain  a  series  of  papers  to 
show  that  many  tumours  of  the  jaws,  classed  as  exostoses, 
are  derived  from  aberrations  of  teeth. 

Whenever  it  seemed  desirable  to  illustrate  the  nature  of  a 
genus  of  tumours  by  reference  to  Comparative  Pathology,  I 
have  not  hesitated  to  do  so.  Without  this  aid,  any  attempt 
to  catch  the  deeper  meaning  of  many  tumours  is  as  difficult 
as  endeavours  to  decipher  a  palimpsest  in  which  the  first 
characters,  written  in  an  unknown  tongue,  have  been  im- 
perfectly removed  from  the  parchment,  and  are  allowed  to 
mingle  with  the  second  inscription. 


CONTENTS 


Introduction  .        .        . 

. 

1 

CHAPTER 

1.  Lipomas 

.       12 

2.  Chondromas 

.       26 

3.  Osteomas 

.       34 

4.  Myelomas 

.       45 

5.  Sarcomas 

.       52 

6.  Sarcomas  (continued) 

.       62 

7.  Sarcomas  of  Bones 

.      77 

8.  Sarcomas  of  Glandular  Organs 

.       95 

9.  Tumours  of  the  Adrenal 

.     106 

10.  Pigmented  Tumours 

.     110 

11.  Moles       ..... 

.     123 

12.  Neuromas         .... 

.     130 

13.  Neuromas  (continued)     . 

.     140 

14.  Neuromas  (concluded) :    Gliomas 

.     148 

15.  Angeiomas  and  Lymphangeiomas 

.     156 

16.  Uterine  Fibroids   .        .        .        . 

.     168 

17.  Uterine  Fibroids  (continued) 

.     180 

18.  Uterine  Fibroids  (continued) 

.     187 

19.  Uterine  Fibroids  (continued) 

.     195 

20.  Uterine  Fibroids  (concluded) 

.     206 

21.  Odontomas 

.     211 

22.  Papillomas       .... 

.     234 

CONTENTS 


CHAPTER 

23.  Horns 

24.  Adenoma  .        • 

25.  Carcinoma 

26.  Concerning  the  Cause  of  Cancer 

27.  Treatment  of  Malignant  Tumours 

28.  Carcinoma  of  the  Breast     . 

29.  Carcinoma  of  the  Breast  {concluded) 

30.  Epithelial  Tumours  of  Sebaceous  Glands 

31.  Epithelial  Tumours  of  the  Thyroid  Gland 

32.  Carcinoma  of  the  Lips,  Mouth,  Tongue,  etc. 

33.  Carcinoma  of  the  O^Isophagus,  etc. 

34.  Epithelial  Tumours  of  the  Liver,  etc. 

35.  Carcinoma  of  the  Urinary  Organs,  etc 

36.  Epithelial  Tumours  of  the  Uterus    . 

37.  Epithelial  Tumours  of  the  Uterus  (conti 

38.  Uterine  Fibroids  and  Cancer 

39.  Papilloma  and  Carcinoma  of  the  Tube 

40.  Endotheliomas 

41.  Chorion-Epithelioma     .... 

42.  Teratomas 

43.  Teratomas  [concluded) 

44.  Sequestration  Dermoids 

45.  Sequestration  Dermoids  (concluded)   . 

46.  Tubulo-Dermoids 

47.  Cervical  Fistul^e,  etc 

48.  Tumours  of  the  Ovary 

49.  Tumours  of  the   Ovary  {continued)     . 

50.  Tumours  of  the  Ovary   {continued)     . 

51.  TuMOLTis  OF  THE  OvARY    {continued)     . 


nued) 


242 
248 
254 
275 
287 
292 
303 
307 
313 
319 
328 
345 
360 
372 
380 
393 
398 
405 
415 
422 
433 
442 
455 
466 
474 
486 
502 
509 
520 


CONTENTS 

CHAPTER 

52.  Tumours  of  the  Ovary  {concluded) 

53.  Tumours  of  the  Testicle 

54.  Heterotopic  Teeth 

55.  Retention-Cysts 

56.  Retention-Cysts  {concluded) 

57.  Tueulo-Cysts  . 

58.  Hydrocele 

59.  Pseudo-Cysts  . 

60.  Pseudo-Cysts  {continued) 

61.  PsEUDO- Cysts  {continued) :  Neural  Cysts 

62.  Pseudo-Cysts  :  Neural  Cysts  {concluded) 

63.  EcHiNOCoccus  Disease     .... 
Index     


XI 

PAGE 

529 
537 
553 
563 
575 
594 
602 
611 
620 
629 
638 
652 
675 


TUMOURS:    INNOCENT   AND 
MALIGNANT 

INTRODUCTION 

It  has  long  been  customary  in  surgical  writings  to  group 
together  a  ve^ry  heterogeneous  assembly  of  morbid  con- 
ditions under  the  term  Tumours.  This  is  a  very  ancient 
name,  and  merely  means  a  swelling,  but  the  careful  micro- 
scopic investigations  of  morbid  anatomists  with  the  aid  of 
differential  staining  (histologic  chemistry),  and  the  study 
of  the  relationship  of  micro-organisms  to  many  swellings 
called  tumours,  have  led  to  a  revolution  in  our  knowledge, 
so  that  the  term  has  been  stripped  of  its  former  wide 
significance.  In  clinical  work,  the  word  tumour  is  not 
likely  to  disappear,  although  it  has  lost  its  importance  to 
the  pathologist. 

Formerly,  the  term  tumour  was  applied  to  the  abnor- 
mal swellings  which  characterize  the  gummatous  stage  of 
syphilis ;  the  lesions  of  actinomycosis,  leprosy,  and  other 
diseases,  collectively  known  as  the  Infective  Granulomas ; 
the  excessive  formation  of  callus  around  the  fragments  of 
broken  bones,  and  the  exuberant  production  of  cicatricial 
tissue  known  as  keloid.  It  is  noteworthy  that  almost 
every  increase  in  our  knowledge  regarding  the  cause  of 
tumour-diseases  results  in  reducing  the  list  of  morbid  con- 
ditions known  as  tumours,  either  by  removing  some  from 
this  category,  or  by  combining  under  one  term  a  number 
of  apparently  diverse  conditions  which  were  formerly 
regarded  as  independent.  Tumour-diseases  of  the  nervous 
system  illustrate  this.  Among  recent  evictions  from 
tumours  is  the  big  prostate  of  advanced  life,  which  is 
usually     classed     among     adenomas ;     but    some    excellent 

B 


2  '  INTHOBTJGTION 

observations   indicate  that  this  disease,  the   bane   of  elders, 
is  due  to  micro-organisms  which  gain  access  to  the  glandular 
recesses  of  the  prostate  from  the  urethra  and  set  up  inflam 
matory  (reactive)  changes. 

In  ignorance  of  the  cause  of  tumours  (pathogenesis),  we 
fall  back  on  their  minute  structure  (histology)  as  a  basis 
of  classification  (taxonomy).  This  is  the  natural  outcome 
of  the  careful  investigation  of  the  minute  structure  of 
tumours,  because  it  led  investigators  to  realize  that  they 
consisted  of  the  same  tissues  which  compose  the  normal 
organs  of  the  body.  This  was  a  great  step.  Anatomic  ob- 
servations taught  men  that  animal  bodies  are  made  up  of 
diverse  structures,  such  as  fat,  suet,  bone,  gristle,  muscle, 
tendon  and  the  like,  but  the  microscope  revealed  that  they 
are  composed  of  fundamental  tissues,  which  enter  into  the 
construction  of  organs  of  the  most  diverse  form  and  func- 
tion. The  base  is  the  connective  tissues,  comprising  bone, 
fat,  cartilage,  etc.,  and  two  remarkable  structures  known  as 
muscle  and  nerve.  There  is  also  a  peculiar  material  which 
permeates  the  body  and  enters  into  the  composition  of 
every  organ;  it  is  called  areolar  tissue,  a  ubiquitous  web 
which  is  stout  and  strong  as  fascia  and  periosteum,  ex- 
tremely delicate  in  the  nervous  system,  and  so  fine  in  the 
retina  as  to  need  careful  preparation  to  render  it  perceptible 
to  the  microscope.  The  connective  tissues  form  the  frame- 
work of  the  body,  and  constitute  a  sort  of  sustentaculum 
in  compound  organs,  such  as  the  liver,  intestines,  kidney,  and 
the  like,  for  the  support  of  epithelium,  and  serve  as  a 
naesh  in  which  blood-vessels  and  lymphatics  can  ramify  to 
supply  the  liquid  tissue — blood,  from  which  the  epithelial 
cell  can  obtain  material  to  form  the  secretion  which  it  is 
the  function   of  particular  glands  to  elaborate. 

The  careful  and  critical  study  of  the  minute  (micro- 
scopic) structure  of  tumours  having  revealed  that  they  were 
composed  of  tissues  normally  existing  in  the  animal  body, 
pathologists  realized  that  the  histology  and  embryology  of 
an  organ  enable  an  experienced  oncologist  to  predict  the 
various  genera  of  tumours  and  cysts  to  which  it  may  be 
liable.  Thus  the  tibia  of  a  child  contains  cartilage,  bone, 
fibrous  tissue,  young  connective  tissue,  fat,  and  red  marrow. 


LIABILITY  OF  ORGANS  3 

The  epiphysial  cartilages  are  the  source  of  chondromas ; 
the  bone  furnishes  osteomas,  the  periosteum  sarcomas, 
and  very  rarely  lipomas,  and  myelomas  arise  in  the  red 
marrow.  Cancers  do  not  arise  primarily  in  bone,  as  it 
lacks  epithelium,  but  they  often  occur  in  bone  as  secondary 
deposits. 

Although  our  knowledge  of  the  intimate  structure  ot 
tumours,  thanks  to  differential  staining  methods,  is  now 
sutficient  to  enable  us  to  indicate  from  the  structure  of  an 
organ  the  genera  of  tumours  to  which  it  may  be  liable, 
nevertheless,  the  most  careful  study  of  the  minute  struc- 
ture of  such  organs  as  the  salivary  glands  would  not  lead 
us  to  suspect  their  liability  to  pure  chondromas ;  and  it 
is  strange  that"  they  should  occur  in  the  parotid,  sub- 
maxillary, and  lachrymal  glands,  and  yet  be  unknown  in 
the  pancreas.  What  oncologist,  merely  from  studying  the 
histology  of  a  normal  ovary,  would  suspect  that  it  would 
be  the  point  of  origin  of  a  dermoid  ?  It  is  like  studying 
the  fauna  of  a  country.  For  instance,  who  imagined,  until 
Australia  was  discovered,  the  existence  of  extraordinary 
mammals  like  kangaroos  and  duck  moles  ?  But  knowledge 
gained  from  observation  enables  us  to  state  that  gliomas 
do  not  arise  in  bone,  nor  myomas  in  the  brain,  nor  der- 
moids in  the  spleen,  liver,  or  kidney,  with  the  same  cer- 
tainty that  we  assert  that  at  the  present  period  of  our 
planet's  history  lions  do  not  sport  about  the  ice-fields  of 
Greenland,  nor  do  humming-birds  flit  about  the  flower-beds 
of  Hyde  Park. 

It  is,  however,  necessary  to  point  out  that,  although 
the  tissues  of  an  organ  determine  the  genera  of  tumours  to 
which  it  may  be  liable,  their  relative  frequency  can  onlv 
be   gathered  from    observation. 

The  variations  in  the  liability  of  the  organs  of  the 
body  to  tumours  are  a  very  curious  matter.  The  heart  is 
very  rarely  occupied  by  a  tumour  ;  on  the  other  hand,  the 
uterus,  also  a  muscular  organ,  is  with  extreme  frequency 
the  seat  of  fibroids.  The  liability  of  bones  to  sarcomas 
is  proverbial,  yet  a  sarcoma  of  a  voluntary  muscle  is  most 
uncommon.  A  primary  tumour  is  a  rarity  in  the  lung, 
but    it    is    common    enough    in    the    brain    or  the   eyeball. 


4  INTBOBUGTlOK 

Sarcomas  are  frequent  in  the  kidneys,  but  a  primary  sar- 
coma in  the  Hver  or  spleen  is  extremely  rare.  These  and 
many  kindred  questions  indicate  profound  imperfections  in 
our  knowledge  concerning  the  cause  of  tumours.  It  may 
be  stated,  without  fear  of  contradiction,  that  no  one  has 
succeeded  in  framing  a  satisfactory  classification  of  tumours. 
In  this  Avork  the  subjoined  plan  will  be  followed  : — 

Group      I.      Tumour-diseases  of  the  connective  tissues. 

This  will  include  Lipomas,  Chondromas, 
Osteomas,  Myelomas,  Sarcomas,  Myxomas, 
Myomas,  Neuromas,  Angeiomas,  Endo- 
theliomas, and  Uterine  Fibroids. 

Group    II.      Tumour-diseases  of  teeth. 
Odontomas. 

Group   III.      Epithelial  tumours. 

This  comprises  Papillomas  (warts),  Adeno- 
mas, Carcinomas. 

Group   IV.      Endotheliomas. 

This  includes  Hsemendotheliomas,  Lymphen- 
dotheliomas.  Peritheliomas  (Angeio- sarcomas). 

Group     V.      Tumours  arising  from  the  fcetal  membranes. 
Chorion-epitheliomas  (Deciduomas). 

Group   VI.      Teratomas. 
Dermoids. 
Embryomas. 

Group  VII.      Cysts. 

Tumours  have  from  very  early  times  been  arranged 
into  a  mahgnant  and  an  innocent  or  benign  division,  based 
on  the  knowledge  gained  from  observation  that  some  of 
them  inevitably  destroy  life,  w^hilst  others  do  not  disj^lay 
such   destructive   propensities. 

It  is  important  to  remember  that  benign  tumours  may, 
and  often  do,  destroy  life.  The  essential  difference  between 
an  innocent  and  a  malignant  tumour  may  be  expressed 
thus:  The  baneful  effects  of  innocent  tumours  depend 
entirely  on  their  environment,  but  malignant  tumours 
destroy  life  whatever  their  situation. 

Environment  in  relation  to  tumours. —  Although 
throughout  the  whole  of  this  book  reference  will  be  made 


ENVIRONMENT  5 

to  the  destructive  effects  of  turaonrs  of  all  kinds,  which 
will  make  the  reader  realize  the  truth  of  the  words  that 
Byron  puts  into  the  mouth  of  Werner,  "  Death  hath  a 
thousand  gates,"  it  will,  perhaps,  be  useful  to  describe 
some  examples  which  illustrate  the  importance  of  environ- 
ment. A  small  tumour  occupying  a  vital  organ  will 
sometimes  destroy  life  from  mechanical  causes.  For  example  : 
A  girl  aged  14  was  seized  with  paraplegia  and  died  in 
ten  days.  The  cervical  segment  of  the  cord  contained 
a  tumour  of  the  size  and  shape  of  a  small  olive  (Fig.  1). 

Some  of  the  most  tragic  deaths  due  to  tumours  struc- 
turally benign  occur  in  connexion  with  the  air-passages. 
A  man  aged  76  entered  a  restaurant  and  made  an 
incoherent  noise  and  motion  of  his  hand,  which  was  taken 
to  be  a  request  for  water. 
Death  took  place  quite  sud-  White  matter 
denly.      At    the    post-mortem  ^'^Tumour- 

examination  an  ovoid  tumour, 
IJ  inches  in  its  greatest  diame- 
ter, was  found   growing   from 

the   left    gloSSO-epiglottic    folds.       Fig.  l.— Cervical  segment  of  the  cord 

The    larynx    and    tongue    with  in  transverse   section     showing  a 

■^  ,  .  o  tum^our  m  the  grey  substance. 

the  tumour  in  situ  were  sent 

to  the  museum  of  the  Royal  College  of  Surgeons.  Shattock 
reported  the  tumour  to  be  a  lipoma,  and  suggests  that, 
from  some  unusual  act  on  the  part  of  the  patient,  it 
became  engaged  in  the  grasp  of  the  pharyngeal  constrictors 
and  suffocated  him  as  he  involuntarily  attempted  to  swallow 
his  own  tumour. 

A  man  36  years  of  age  was  found  lying  on  his  back 
in  a  street  adjacent  to  the  Middlesex  Hospital,  apparently 
in  a  fit;  when  brought  into  the  casualty-room  he  was 
dead.  At  the  post-mortem  examination  a  tumour  was 
found  connected  with  the  cervical  section  of  the  windpipe, 
embedded  in  a  thick  fibrous  capsule,  its  inner  segment 
being  firmly  fixed  to  the  trachea  between  the  fourth  and 
ninth  semi-rings.  The  tumour,  including  its  capsule,  was 
somewhat  larger  than  a  dove's  q^^  (Fig.  2),  and  it  had 
severely  compressed  the   trachea  (Fig.  3). 

The  tumour  presented  the  microscopic  structure  peculiar 


6  INTEOBUGTION 

to  the  parathjrroid  body.  It  was  probably  an  enlarged  para- 
thyroid. Little  was  known  of  these  peculiar  bodies  when  this 
specimen  came  to  hand  in  1886.  The  capsule  consisted  of 
dense  laminse  of  fibrous  tissue ;  the  tumour  could  have  been 
easily  enucleated  from  its  capsule. 

The  preceding  examples  show  that  the  tumours  classed 
as  benign  or  innocent  are  only  dangerous  when  from  their 


Fig.  2. — An  enlarged  and  encapsuled  parathyroid  body.     It  com- 
pressed the  trachea  and  produced  fatal  dyspncea. 

position  they  mechanically  interfere  with  vital  organs,  or 
obstruct  functions  necessary  to  the  maintenance  of  life. 
Malignant  tumours,  on  the  other  hand,  destroy  life  in 
whatever  situation  they  arise.  Melanomas  illustrate  this 
very  well.  A  man  50  years  of  age  came  under  my  ob- 
servation with  an  intra-ocular  tumour  no  larger  than  a 
cherry-stone  growing  from  the  uveal  tract.  The  eyeball 
was  promptly  excised,  and  the  tumour,  which  in  this  case 
had  a  deep  black  hue,  had  remained  strictly  confined  to  the 
globe.      Within   two  years   this   man   died    with    secondary 


ENVIRONMENT  7 

tumours  in  the  liver  and  many  other  organs ;  his  skin 
turned  quite  black,  melanin  appeared  daily  in  the  urine, 
and  the  free  fluid  in  his  belly  also  contained  pigment  in 
abundance. 

Although  it  is  true  that  malignant  tumours  destroy 
life  in  whatever  situation  they  arise,  nevertheless  environ- 
ment exercises  great  influence  on  the  rapidity  as  well  as 
on  the  mode  in  which  they  kill.  For  instance,  a  cancer 
of  the  larynx  may  cause  death  from  suffocation,  but  it  is 
more  frequently  fatal  by  setting  up  septic  pneumonia  in 
consequence  of  the  inhalation  of  septic  matter  from  the 
sloughing   surface   of    the   growth.      Cancer   of    the   gastric 


Fig.  3.  —Section  of  an  enlarged  parathyroid  body  and  trachea,  showing 
the  amount  of  stenosis.     (iV«^.  size.) 

orifices  usually  entails  death  from  starvation,  and  malig- 
nant disease  of  the  prostate  destroys  life  by  leading  to 
renal  disorders  consequent  upon  impediment  to  the  free 
escape  of   urine   from  the  bladder. 

It  may  be  stated  almost  as  an  axiom  that  when  a 
malignant  tumour  implicates  a  vital  organ  it  will  often 
destroy  life  before  there  has  been  time  for  dissemination. 
When  the  environment  has  been  unfavourable  in  this 
respect  death  is  usually  induced  by  secondary  nodules 
occupying  important  organs,  e.g.  lungs,  liver,  brain,  etc. 
This  is  a  matter  which  will  receive  careful  attention  in 
the  description  of  malignant  disease  as  it  attacks  different 
organs.  It  is,  however,  a  very  remarkable  fact  that  a  peri- 
osteal sarcoma  of  the  femur  is  the  most  deadly  tumour 
which    attacks   the    human   frame,   but   a   sarcoma   of    the 


8  INTRODUCTION 

tibia  with  the  same  histologic  characters  will,  with  pre- 
cisely the  same  treatment  (amputation),  take  as  many  years  to 
destroy  life  as  the  tumour  of  the  femur  requires  months. 
This  would  appear  to  indicate  that  the  two  tumours, 
though  structurally  alike,  really  have  different  causes,  yet 
there  are  facts  which  lead  us  to  suspect  that  variations 
in  tissue  actually  constitute  an  altered  environment.  The 
only  condition  which  supports  this  view  in  a  positive  way 
is  echinococcus-disease.  The  final  chapter  of  this  book  con- 
tains abundant  evidence  as  to  the  effects  of  environment 
on  the  character  of  echinococcus  colonies,  besides  illustrat- 
ing the  varied  manner  in  which  the  surroundings  deter- 
mine the  mode  by  which  these  parasites  often  induce  the 
death  of  human  beings,  their  involuntary  intermediate  hosts. 
Some  of  the  most  terrible  examples  illustrating  danger- 
ous environment  are  inconspicuous  solid  ovarian  tumours 
and  dermoids,  incarcerated  in  the  pelvis  by  a  gravid  uterus. 
In  many  instances  the  presence  of  a  tumour  is  unsus- 
pected even  when  the  woman  has  been  hours  in  labour. 
Obstruction  of  this  kind  is  very  fatal  to  the  child  and 
often  to  the  mother,  and  the  injuries  Avhich  women  sus- 
tain in  such  circumstances  are  often  of  an  appalling 
character,  as  works  on  midwifery  testify.  Even  when 
ovarian  tumours  do  not  obstruct  delivery,  their  co-exist- 
ence with  pregnancy  is  an  inimical  condition,  and  may 
bring  about  the  death  of  the  mother  either  in  the 
progress  of  the  pregnancy,  during  labour,  or  in  puerpery. 
There  are  some  anatomical  conditions  which  distinguish 
innocent  from  malignant  tumours :  those  that  are  benign 
usually  possess  an  investing  membrane,  or  capsule,  by 
which  they  are  isolated  from  the  tissues  in  which  they 
grow;  they  do  not  infect  lymph-glands,  nor  recur  after 
complete  removal,  and  rarely  imperil  life  save  when  grow- 
ing in  connexion  with,  or  in  the  immediate  vicinity  of, 
vital  organs.  Malignant  tumours,  on  the  other  hand,  are 
rarely  encapsuled,  and  tend  to  infiltrate  the  surrounding 
tissues ;  they  infect  the  lymph-glands  which  receive  the 
lymphatics  from  the  part  affected,  are  exceedingly  liable 
to  recur  after  removal,  tend  to  become  disseminated  by  the 
lymph-  and  blood-stream,  and  inevitably  destroy  life. 


AGE-DISTRIBUTION  9 

Age-distribution. — Although  some  tumours  may  occur 
at  any  period  of  life — e.g.  fatty  tumours  and  sarcomas — 
the  majority  of  the  genera  have  a  fairly  well-defined,  and 
occasionally  a  very  strict  age-limit.  For  example,  the 
species  of  tumour  known  as  glioma,  which  arises  in  the 
retina,  has  rarely  been  observed  after  the  twelfth  year ; 
it  is  peculiarly  limited  to  infants,  and  this  is  also  the  case 
with  the  remarkable  condition  known  as  "gliomatous 
disease"  of  the  pons  and  medulla.  Myelomas  are  tumours 
of  adolescence ;  and  this  is  true  of  odontomes,  for  they 
only  arise  in  connexion  with  the  germs  of  the  permanent 
teeth.  Uterine  fibroids  are  produced  during  menstrual 
life,  and  careful  inquiry  demonstrates  that  the  dread 
chorion-epithelioma  (deciduoma)  is  a  by-product  of  concep- 
tion, and  therefore  restricted  to  the  child-bearing  period 
of  life.  Parovarian  cysts  do  not  occur  before  the  fifteenth 
year,  and  papillomatous  cysts  of  the  ovary  are  fairly  well 
distributed  to  the  three  decades  bounded  by  the  twenty- 
fifth  and  fifty-fifth  years.  Angeiomas  and  sequestration 
dermoids  are  essentially  congenital  tumours,  whilst  melano- 
mas are  almost   confined  to  adults. 

It  may  with  truth  be  stated  that  age  constitutes  an 
environing  condition  when  we  reflect  that  sarcoma  in  in- 
fancy tends  to  be  bilateral — e.g.  when  it  attacks  the  kidneys, 
eyes,  adrenals,  or  ovaries.  In  adult  life  sarcoma  of  these 
same  organs  is  invariably  unilateral;  but,  apart  from  this 
peculiarity,  as  many  of  the  subsequent  chapters  will  show, 
the  tumours  at  these  diverse  periods  of  life  exhibit  obvi- 
ous and  unmistakable  differences  in  their  minute  structure. 

Multiplicity. — Innocent  tumours  are  often  multiple :  five, 
ten,  or  twenty  lipomas  on  an  individual  are  not  un- 
common numbers.  A  thousand  neuromas  have  been  counted 
on  one  patient  ;  a  hundred  fibroids  may  grow  concurrently 
in  the  tissues  of  the  uterus,  and  ten  adenomas  occasion- 
ally occupy  a  single  thyroid  gland,  but  the  occurrence  of 
two  primary  cancers  in  the  same  patient  is  excessively 
rare,  with  the  exception  of  the  peculiar  variety  known  as 
rodent  cancer. 

The  co-existence  in  the  same  person  of  two  genera  of 
mnocent  tumours  is  well  known — indeed,  is  almost  a  matter 


10  INTRODUCTION 

of  daily  observation,  uterine  fibroids  and  ovarian  dermoids, 
lijDomas  and  sequestration  dermoids,  chondromas  and  osteo- 
mas being  frequent   combinations. 

An  individual  may  have  one  or  more  innocent  tumours 
for  many  years,  and  then  a  carcinoma  may  arise,  some- 
times in  an  organ  abeady  occupied  by  a  tumour.  For 
example,  the  uterus  may  be  the  seat  of  a  large  fibroid, 
and  carcinoma  may  subsequently  arise  in  the  endometrium. 
Carcinoma  and  adenoma  occasionally  grow  concurrently 
in  the  same  breast ;  or  cancer  may  arise  in  the  mamma  a 
year  or  more  after   the  removal  of  an  ovarian   tuinour. 

The  transformation  of  innocent  into  malignant  tu- 
mours.— A  long  study  of  the  histogenesis  of  tumours  has 
convinced  the  writer  that  the  clearly  innocent  and  the 
decidedly  malignant  tumours  present  distinct  histologic 
features,  but  there  are  intermediate  varieties  which  cannot 
be  sharply  defined  in  relation  to  these  points,  and  this 
comes  out  in  a  striking  and  suggestive  way  when  an  in- 
dividual possesses  tumours  of  a  supposed  innocent  genus  in 
multiples :  for  example,  from  uterine  fibroids,  when  they  are 
multiple,  a  tumour  may  be  selected  which  sometimes  re- 
quires a  saw  to  divide  it  ;  another  may  be  as  soft  as  a 
ripe  fig,  and  a  third  will  be  as  viscous  as  jelly  and  almost 
diffiuent :  a  soft  fibroid  of  this  character  Avill  sometimes 
recur  after  enucleation.  Careful  records  are  accessible  in 
which  fibroids  of  apparently  simple  structure  have  dissemi- 
nated and  destroyed  life ;  it  should  be  borne  in  mind  that 
the  uterus  is  liable  to  be  the  seat  of  a  sarcoma  which,  in 
the  early  stages,  mimics  a  fibroid  in  its  naked-eye  characters. 

It  is  so  difficult  to  decide  between  the  slow-growing 
spindle-cell  sarcoma,  the  fibrifying  sarcoma,  and  the  gela- 
tinous fibroid  (myxoma)  that  it  is  unwise  to  argue  from  our 
present  knowledge  that  innocent  connective-tissue  tumours 
may  undergo  transformation  into  sarcomas  until  distinctive 
methods  have  been  introduced  by  the  histologist,  chemist, 
biologist,  or  bacteriologist.  It  may  be  stated  that  every 
genus  of  the  connective-tissue  group,  with  the  exception 
of  the  lipomas,  presents  varieties  which  shade  away  indefi- 
nitely from  the  typical  species  towards  the  sarcomas,  and 
display  malignancy.     It  is  also  clear,  from  a  careful  study  of 


MALIGNANT   TRANSFORMATION  11 

the  histology  of  tumours,  that  the  more  perfectly  they  ap- 
proach in  type  normal  tissues  the  more  benign  is  their 
clinical  conduct;  and  the  more  widely  the  tissues  of  a  tumour 
depart  from  the  normal  elements  in  which  they  arise,  so 
much  more  likely  are  such  tumours  to  be  malignant.  It 
may  be  stated  that  a  wide  departure  from  the  normal 
type  of  tissue  in  a  given  tumour  expresses  the  degree  of 
malignancy.  Certainly  the  more  widely  the  cells  of  a  tumour 
deviate  from  those  normal  to  the  matrix  in  which  it  grows 
the  more  rapidly  do  they  multiply ;  and  this  persistent  cell- 
proliferation  is  one  of  the  most  obvious  features  of  mahg- 
nancy.  The  more  carefully  the  histology  of  tumours  is 
investigated,  the  more  obvious  is  it  that  the  border- 
land between  innocent  and  malignant  species  becomes 
less  easily  definable.  This  has  been  very  definitely  revealed 
in  the  case  of  ovarian  dermoids ;  few  tumours  had  a  better 
reputation  for  innocency,  yet  we  now  know  that  the  less 
typical  forms  are  liable  to  infect  the  peritoneum  and  even  dis- 
seminate, and  some  varieties  of  testicular  embryomas  are 
among  the  most  malign  tumours  that  attack  mankind. 
Kealizing  the  uncertainty  attending  the  diagnosis  and  prog- 
nosis of  tumours  and  tumour-diseases,  pathology  confirms 
the  practice  advocated  by  surgeons  in  dealing  with  them, 
namely,  removal,  whenever  practicable,  at  the  earliest 
possible  moment. 


GROUP  L    CONNECTIVE-TISSUE  TUMOURS 

CHAPTER   I 
LIPOMAS  (FATTY  TUMOURS) 

A  LIPOMA  is  a  tumour  composed  of  fat;  the  genus  consists 
of  a  single  species.  With  the  exception  of  sarcoma  it  is 
the  naost  generalized  genus  of  tumours  which  occurs  in 
man.  It  therefore  will  be  convenient  to  consider  lipomas 
according  to  the  situations  in  which  they  arise,  such  as 
the  subcutaneous  and  subserous  tissues ;  beneath  synovial 
or  mucous  membranes  ;  between  or  even  in  muscles;  or  in 
connexion  with  periosteum,  and  the  meninges  of  the  brain 
and  spinal  cord. 

The  distribution  of  fat  in  the  animal  body  is  comparable 
to  that  of  starch  in  the  vegetable  kingdom,  where  it  also  takes 
on   a  tumour-like  form,  as  in  conns  and  tubers  (Shattock). 

1.  Subcutaneous  lipomas. — Beneath  the  skin  there  exists 
a  layer  of  fat  which  varies  in  thickness  in  different 
parts,  but  is  most  abundant  over  the  trunk  and  trunk- 
ends  of  the  limbs.  This  subcutaneous  fat  is  a  common 
situation  in  which  to  find  fatty  tumours.  Usually  they  occur 
as  irregularly  lobulated  encapsuled  tumours,  more  or  less 
adherent  to  the  skin :  unless  they  have  been  irritated, 
lipomas  are  movable  within  their  capsules.  Generally  one 
lipoma  is  present,  but  two,  ten,  twenty,  or  more  may  occur 
concurrently^  on  the  same  individual.  In  size  they  vary 
widely;  a  lipoma  weighing  sixteen  ounces  is  a  tumour 
of  fair  size ;  exceptional  specimens  have  been  reported 
to  weigh  fifty,  eighty,  and  even  one  hundred  pounds. 
Although  subcutaneous  lipomas  are  for  the  most  part 
confined  to  the  trunk  and  trunk-ends  of  limbs,  they  may 
arise  on  the  distal  parts  of  the  limbs,  such  as  the  hands 
and    feet    (Figs.    4    and    5).      Many    specimens   have    been 

12 


LIPOMAS 


13 


observed  in  the  palm  of  the  hand,  a  situation  in  which 
they  are  apt  to  give .  rise  to  difficulty  in  diagnosis,  more 
especially  as  they  simulate  compound  ganglia  of  the  flexor 
tendons.  The  lobes  of  fat  are  apt  to  burrow  beneath 
the  palmar  fascia,  and  it  is  probable  that  some  lipomas 
of  the  palm  originate  beneath  this  fascia,  in  the  lobules  of 
fat  lying  between  the  lumbricales.  A  lipoma  has  been 
observed   on   the   back   of  the  hand  of  a  boy  8  years  old. 


Fig.  4. — Lipoma  of  the  sole  which  had  existed  for  thirty  years.     It  was  removed  by 
Percivall  Pott.     {Musetim  of  St.  Bartholomeic'' s  IlospitaL) 

and  a  process  of  the  tumour  passed  between  the  third  and 
fourth  metacarpals  into  the  palm  (Pupovac).  Fatty  tumours 
are  occasionally  found  on  the  fingers :  Steinheil  has  col- 
lected a  large  number  of  examples.  A  lipoma  in  the  sole 
is  more  comprehensible  than  one  in  the  palm,  yet,  strange 
to  relate,  the}'"  are  far  more  frequent  in  the  hand  than  in 
the  foot ;  in  both  situations  they  are  apt  to  be  congenital, 
and  nearly  always  cause  doubt  in  diagnosis  (Gay,  Lockwood). 
Fatty  tumours  are   rarely  met  with  upon    the  head  or 


14 


GONNEGTIVB-TISSUE    TUMOURS 


face,  but  I  have  on  three  occasions  removed  a  lipoma  from 
beneath  the  skin  covering  the  temporal  fascia.  There  is  a 
variety  of  fatty  tumour  sometimes  called,  on  account  of  its 
vascularity,  ncevo-lipoma :  this  may  be  a  nsevus  which  has 
undergone  fatty  degeneration.  Probably  some  of  the  vascular 
lipomas  which  occasionally  occur  on  the  face  are  of  this  nature. 
Fatty  tumours   which   have   existed   many   years   some- 


Fig.  5. — Lipoma  in  the  palm. 

times  calcify,  the  earthy  matter  being  deposited  in  the 
fibrous  septa  of  the  tumours.  A  partially  calcified  lipoma 
is  preserved  in  the  museum  of  St.  Bartholomew's  Hospital, 
which  came  from  the  arm  of  an  Arab  sheikh,  where  it 
had  existed  fifty  years.  Calcification  may  be  associated 
with  saponification  of  the  fat. 

The  subcutaneous  fat  in  the  neck,  axilla,  and  groin 
sometimes  forms  irregularly  lobulated  masses  called  diffuse 
lipomas,  but  they  are  not  strictly  tumours  (Fig.  6). 


LIPOMAS  15 

2.  Subserous  lipomas. — The  peritoneum,  like  the  skin, 
rests  upon  a  bed  of  fat,  the  thickness  of  which  varies  con- 
siderably. Lipomas  occurring  in  subserous  tissue  are  sessile, 
or  pedunculated. 

Surgeons  have  long  been  aware,  in  operating  for  in- 
guinal or  femoral  hernia,  that  occasionally  they  come  across 
a   mass   of  fat   and   find   difficulty  in   determining  whether 


Fig.  6. — Diffuse  lipoma  of  the  neck.     [After  Morrant  Baker.) 

it  be  omental  or  a  local  increase  of  the  subserous  fat  sur- 
rounding the  hernial  sac.  It  is  now  clear  that  in  the 
neighbourhood  of  the  femoral  and  inguinal  canals  an  over- 
growth of  the  subserous  fat  may  occur  and  be  mistaken 
for  a  hernia,  and  individuals  have  been  recommended  to 
wear,  and  have  actually  worn,  trusses  for  fatty  masses  of 
this  character.  It  is  also  clear  that,  as  these  local  over- 
growths of  fat  arise  and  protrude  in  the  groin,  they 
occasionally  draw  with  them  a  pouch  of  peritoneum  un- 
associated   with   a  hernia.      These   pouches    may  afterwards 


16  G0NNEGTIVE-TI8SUE   TUMOURS 

lodge  a  piece  of  gut,  and  become  true  hernial  sacs.  Thus 
peritoneal  pouches,  produced  mechanically  by  subserous  lobes 
of  fat,  may  subsequently  become  hernial  sacs ;  on  the 
other  hand,  pedunculated  lobes  of  fat  may  arise  in  relation 
with  peritoneal  pouches  which  were  originally  hernial  sacs.  In 
some  cases  a  subserous  lipoma  of  this  character  will  invagi- 
nate  a  peritoneal  pouch  and  form  a  pedunculated  tumour 
within  the  hernial  sac.  More  rarely  a  fatty  tumour  will 
arise  in  connexion  with  the  spermatic  cord.  Gabryszewski 
has  collected  the  more  important  cases,  and  discussed  the 
difficulty  such  tumours  cause  in  diagnosis.  Andrewes  found 
a  tumour  which  appeared  to  be  a  lipoma  of  the  sper- 
matic cord,  but  on  microscopic  examination  it  exhibited 
the  structure  of  an  adrenal.  Fatty  tumours  arise  in  the 
scrotum  or  labium  without  being  connected  with  hernial 
pouches  (Hutchinson). 

Lipomas  arising  in  the  subperitoneal  tissue  occasionally 
appear  in  the  anterior  abdominal  wall,  especially  near 
the  umbilicus ;  they  are  known  as  "  fatty  hernise  of  the 
linea  alba,"  and  are  frequently  associated  with  peritoneal 
pouches. 

Fatty  tumours  sometimes  grow  between  the  layers  of  the 
mesometrium,  and  in  some  instances  are  so  large  as  to 
simulate  ovarian  tumours  (Parona,  Treves). 

Masses  of  fat,  in  many  respects  resembling  the  so-called 
"  diffuse  lipoma "  of  the  subcutaneous  tissue,  have  been  re- 
moved from  the  abdomen,  weighing  thirty  and  even  fifty 
pounds  (Pick,  Cooper  Forster). 

Hernial  lipomas  are  interesting,  for  they  explain  the 
mode  in  which  appendices  epiploicse  arise :  these  are 
localized  pedunculated  overgrowths  of  subserous  fat,  and 
are  particularly  large  and  arborescent  in  the  neighbourhood 
of  an  old  syphilitic   stricture  of  the  rectum. 

In  well-nourished  individuals  the  fat  of  the  appendices 
epiploicse  is  directly  continuous  with  the  fat  in  the  layers 
of  the  mesentery;  when  wasting  occurs  the  fat  between  the 
appendices  and  the  mesentery  is  liable  to  atrophy  and  to  leave 
an  adipose  nodule  at  the  bottom  of  a  peritoneal  pouch.  The 
movements  of  the  intestine  and  the  traction  of  the  nodule 
lead    to    the    formation  of  a  pedicle   which   often   becomes 


LIPOMAS  17 

twisted  ;  sometimes  tlie  pedicle  is  so  thin  that  it  breaks, 
and  the  appendix  is  set  free.  Pieces  of  fat,  not  infrequently 
calcified,  detached  in  this  way,  have  been  found  in  hernial  sacs. 

A  fatty  tumour  may  arise  in  the  fat  behind  the  ensiform 
cartilage,  and,  extending  through  the  gap  in  the  diaphragm 
in  this  situation,  occupy  the  lower  end  of  the  anterior 
mediastinum. 

Rokitansky  pointed  out  that  the  subpleural  fat  in  the 
intercostal  region  sometimes  forms  a  lobulated  mass  which 
prolapses  into  the  sac  of  the  pleura.  C.  Gussenbauer  has 
described  and  figured  a  subpleural  lipoma  which  made  its 
way  on  each  side  of  the  ribs.  The  two  lobes  were  joined 
by  a  narrow  isthmus  so  as  to  form  an  intra-  and  an  extra- 
thoracic  portion;  the  latter  bulged  under  the  pectoralis 
major  and  simulated   a  sarcoma. 

3.  Submucous  lipomas. — Fat  exists  in  submucous  tissue 
in  many  situations,  and,  like  that  in  the  subcutaneous  tissue, 
is  not  infrequently  the  source  of  lipomas. 

(a)  Subconjunctival  lipomas. — These  occur  near  the 
line  where  the  conjunctiva  is  reflected  from  the  lower  lid 
to  the  eyeball ;  they  are  almost  entirely  confined  to  chil- 
dren. Fatty  tumours  sometimes  arise  from  the  orbital  fat 
and  cause  the  conjunctiva  to  protrude  in  the  neighbour- 
hood of  the  lachrymal  gland  and  near  the  insertions  of  the 
ocular  muscles. 

(6)  The  lips. — Lipomas  in  this  situation  are  very  rare 
and  never  large  (Edmunds). 

(c)  Laryngeal  lipomas. — A  few  remarkable  examples 
have  been  reported.  Holt  met  with  a  pedunculated  lipoma 
22-5  cm.  in  length,  which  grew  from  the  side  of  the  left 
aryteno-epiglottic  fold  and  extended  into  the  cesophagus. 
Sidney  Jones  removed  a  lipoma  from  the  right  aryteno- 
epiglottic  fold  of  a  man  40  years  of  age.  The  patient 
could  protrude  the  tumour  into  his  mouth.  (See  also 
Shattock's  case,  p.  5.) 

(d)  Gastric  lipomas. — Virchow  has  figured  a  lipoma  which 
grew  beneath  the  mucous  membrane  near  the  pylorus ;  it 
was  as  big  as  a  nut. 

(e)  Intestinal  lipomas. — A  submucous  fatty  tumour  of 
the   small  or  the  large  intestine  is  very  rare,   and  in  both 

c 


18  G0NNEGTIVE-TI8SUE    TUMOURS 

situations  may  be  occasionally  inimical  to  life.  The  danger 
of  a  lipoma  of  the  ileum  is  well  set  out  in  a  case  recorded 
by  Stabb  ;  the  tumour  arose  in  the  submucous  tissue  75  cm. 
from  the  ileo-csecal  valve  ;  in  size  and  shape  it  resembled 
three  acorns  conjoined  at  the  cups,  and  it  caused  intussus- 
ception of  the  bowel.  The  invagination  was  reduced  and 
the  tumour  excised.  Unfortunately  the  mucous  membrane 
sloughed,  and  the  patient,  a  man  of  32  years,  died.  The 
specimen  is  preserved  in  the  museum  of  St.  Thomas's 
Hospital. 

I  successfully  removed  from  a  man  44  years  of  age  a 
lipoma,  weighing  two  ounces,  which  occupied  the  submucous 
tissue  of  the  ascending  colon,  5  cm.  above  the  ileo-csecal 
valve.  The  patient  had  passed  through  several  acute 
attacks  of  intestinal  obstruction.  During  the  operation  in 
this  case  I  saw  that  the  serous  coat  over  the  tumour  was 
dimpled.  Stabb  noticed  the  same  condition  in  his  case,  so 
that  it  is  quite  possible  that  these  lipomas,  though  pro- 
jecting into  the  gut,  really  arose  in  the  subserous  stratum 
of  fat. 

Submucous  fatty  tumours  have  been  observed  on  several 
occasions  in  the  jejunum  and  colon.  The  great  danger  is, 
of  course,  their  liability  to  obstruct  the  intestine.  The 
literature  of  intestinal  lipomas  has  been  collected  by 
Hillier,  Langemak,  and  Shattock. 

4.  Subsynovial  lipomas. — Beneath  the  subserous  tissue 
of  large  joints,  such  as  the  knee,  there  is  a  layer  of  fat  of 
varying  thickness.  This  fat  may,  as  in  the  case  of  inguinal 
lipomas,  increase  in  quantity  and,  projecting  into  the 
joint,  form  a  fatty  tumour.  A  common  situation  for  this 
to  occur  is  beside  the  patella,  at  the  spot  normally  occu- 
pied by  the  alar  ligaments.  Many  specimens  are  doubtless 
due  to  overgrowth  of  the  fat  in  the  alar  fringes,  but  they 
may  arise  in  other   parts  of  the  joint. 

The  best-known  variety  of  subsynovial  fatty  tumour 
is  that  to  which  Mtiller  applied  the  term  "lipoma  arbor- 
escens."  This  condition  is  often,  but  by  no  means  always, 
associated  with  rheumatoid  arthritis.  A  typical  specimen 
(Fig.  7)  consists  of  small  finger-like  processes  of  fat  pro- 
jecting into  the  cavity  of  the  joint ;  each  process  is  covered 


LIPOMAS 


19 


with  synovial  membrane.  The  hpoma  arborescens  bears  pre- 
cisely the  same  relation  to  the  synovial  membrane  that 
the  appendices  epiploicse  bear  to  the  peritoneal  investment 
of  the  colon  and  its  sigmoid  flexure. 

5.  Intermuscular  lipomas.  —  Fatty  tumours  now  and 
then  arise  in  the  connective  tissue  between  muscles  ;  they 
have  been  found  between  the  greater  and  lesser   pectorals, 


Fig.  7. — Lipoma  arborescens  of  the  shoulder-joint. 
A,  Acromion.        C,  CoracoiJ.        F,  Glenoid  fossa. 

between  the  muscles  of  the  tongue,  and  the  intermuscular 
strata  of  the  anterior  abdominal  wall.  In  the  last-men- 
tioned situation  they  have  been  known  to  attain  prodigious 
proportions.  Exceptional  examples  have  been  described  by 
Astley  Cooper,  Eve,  and  others. 

The  most  remarkable  example  of  this  variety  of  lipoma 
arises  in  connexion  with  the  sucking-cushion  (Fig.  8).  This 
curious   ball   of  fat   is   situated  between   the   masseter  and 


20 


00NNEGTIVE-TIS8UE    TUMOUBS 


buccinator  muscles,  and  comes  into  close  relation  with  the 
buccal  mucous  membrane.  It  is  believed  to  play  an  impor- 
tant function  in  connexion  with  sucking,  by  distributing 
atmospheric  pressure  and  preventing  the  buccinators  from 
being  forced  between  the  alveolar  arches  when  a  vacuum 
is  created  in  the  mouth.  These  cushions  are  relatively  much 
larger  in  infants  than  in  adults.  Ranke  also  points  out 
that  in  emaciated  children  they  are  only  slightly  diminished 
in  size,  even  when  there  is  scarcely  any  subcutaneous  fat. 


f  y/ 


Pig.  8. — Emaciated  child  crying  and  displaying  sucking- cushions. 
{After  Ranke.) 

The  hibernating  gland. — In  animals  which  pass  the  winter 
in  sleep,  such  as  the  hedgehog,  dormouse,  and  marmot, 
masses  of  fat  accumulate  in  the  neck  and  under  the 
scapula  as  winter  approaches ;  this  fat  dwindles  during 
hibernation,  and  disappears  at  the  advent  of  spring.  Hatai 
and  Shattock  have  come  independently  to  the  conclusion 
that  the  fat  of  this  hibernating  gland  differs  in  some  of  its 
microscopic  characters  from  common  fat.  In  the  human 
subject  they  find  that  some  of  the  deeply  seated  fat  in  the 
neck  corresponds  in  disposition  and  structure  to  that  of  the 
hibernating  or  interscapular  gland.  This  layer  of  fat  exists 
in  the  normal  human  foetus  before  term  (Fig.  9). 


LIPOMAS 


2J 


6.  Intramuscular  lipomas. — Many  examples  of  fatty 
tumours  occurring  in  the  midst  of  muscles  have  been 
reported,  and  are  of  interest  from  the  trouble  they  cause 
in  diagnosis.  They  have  been  found  in  the  deltoid,  biceps 
humeri,  complexus,  and  rectus  abdominis ;  and  in  the  middle 
of  a  submucous   fibroid   of  the   uterus   (T.  Smith,   Lebert). 


Fig.  9. — A  foetus  of  ij^  months  dissected  to  show  the  hibernating  gland. 
(After  Bomiot.) 

The  condition  described  as  fatty  tumour  of  the  heart  is 
simply  overgrowth  of  the  fat  occupying  the  auriculo-ven- 
tricular  grove. 

7.  Parosteal  lipomas. — This  term  has  been  applied  to 
fatty  tumours  arising  from  the  periosteum  of  bone.  When 
congenital,  they  nearly  always  contain  tracts  of  striated 
nmscle  fibre.  Some  of  these  tumours  are  clinical  puzzles. 
Fatty  tumours  have  been  found  growing  from  the  peri- 
osteum of  vertebrse,  the  femur,  tibia,  fibula,  clavicle,  scapula, 
radius,  coccyx,  ischium,  spine  of  ilium,  and  body  of  the  pubes. 


22  CONNECTIVE-TISSUE    TUMOURS 

8.  Lipomas  on  nerves. — Occasionally  a  fatty  tumour 
arises  from  the  sheath  of  a  peripheral  nerve ;  this  is  a 
neuro-lipoma.  There  is  a  specimen  in  the  museum  of 
the  Middlesex  Hospital  which  grew  from  the  sheath  of 
the  median  nerve  as  it  escaped  from  the  anterior  annular 
ligament  into  the  palm.  It  was  situated  entirely  beneath 
the  palmar  fascia.  Vickery  succeeded  in  removing  a  lipoma 
weighing  12|  ounces  from  the  thigh  of  an  infant  9  months 
old.      The    tumour  grew    from    the    sheath    of    the    great 


Fig.  10. — Infant  9  months  old  witli  a  large  lipoma  growing  among  the  hamstring 
muscles.    It  was  successfully  removed.     {After  Vickery.) 

sciatic  nerve.  Before  operation  the  growth  simulated  a 
sarcoma.     (Fig.   10.) 

9.  Meningeal  lipomas. — Fatty  tumours  occur  within  the 
spmal  dura  mater,  as  well  as  externally  to  this  membrane. 
When  growing  within  the  sheath  they  surround  the  cord: 
Gowers,  Recklinghausen,  and  Obre  have  recorded  examples. 
In  the  cases  described  by  the  first  two  observers  the  tumours 
contained  striped  muscle  tissue.  The  occurrence  of  an  intra- 
dural lipoma  is  not  surprising,  as  the  loose  connective  tissue 
between  the  cord  and  dura  mater  contains  fat. 

Fatty  tumours  are  not  uncommon  in  the  middle  line  of 
the  back,  especially  in  the  lumbo -sacral  region,  overlying  the 
sac  of  a  spina  bifida.     (Fig.  11.) 


LIPOMAS' 


23 


A  lipoma  has  been  observed  encapsuled  between  the  layers 
of  the  dura  mater  lining  the  sella  turcica ;  it  extended  into  the 
middle  fossa  of  the  skull  on  the  left  side.  The  patient,  who 
was  a  woman  44  years  of  age,  suffered  from  periodical  pain  in 
the  head,  and  eventually  from  ptosis  (two  years).  The  tumour 
was  as  big  as  a  hen's  egg. 


Fig.  11. — Meningeal  lipoma  overlying  the  sac  of  a  spina  bifida. 
{Museum,  Royal  College  of  Surgeons.) 

Clinical  features. — Although  lipomas  occur  more  fre- 
quently than  any  other  genus  of  connective-tissue  tumours, 
and  may,  in  most  instances,  be  diagnosed  with  absolute 
certainty,  yet  under  some  conditions  they  are  very  puzzling, 
and  give  rise  to  much  difference  of  opinion.  The  sub- 
cutaneous species  is  rarely  the  source  of  doubtful  diag- 
nosis, unless  situated  in  the  palm,  the  sole,  or  on  the 
scalp.  The  intimate  relation  between  the  tumour  and 
the  overljdng  skin,  the  absence  of  definite  boundaries, 
and  its  dough-like  consistence  are  usually  sufficiently  trust- 


24  OONNEGTIVE- TISSUE    TUMOURS 

worthy  guides.  When  a  Hpoma  is  connected  with  the 
periosteum  of  the  femur,  the  tibia,  or  the  fibula  it  simulates  a 
sarcoma ;  when  embedded  in  a  muscle  the  most  divergent 
opinions  are  often  expressed  in  regard  to  the  nature  of  the 
tumour ;  and  a  lipoma  in  the  posterior  triangle  of  the  neck 
has  been  mistaken  for  an  aneurysm  of  the  subclavian  artery. 

Reference  has  already  been  made  to  those  large  lipomas 
which  arise  in  the  subperitoneal  tissue,  and  the  way  in  which 
they  mimic  the  signs  of  ovarian  tumours.  A  lipoma  in  the 
groin  is  occasionally  mistaken  for  an  irreducible  epiplocele. 

Especial  attention  must  be  drawn  to  supposed  fatty 
tumours  situated  in  the  middle  line  of  the  back:  in  most 
cases  these  are  abnormal  masses  of  fat  overlying  the  sacs  of 
spinse  bifidse.  Incautious  surgeons,  in  operating  upon  such 
tumours,  have  unexpectedly  opened  the  dura  mater. 

Treatment. — Solitary  subcutaneous  lipomas  should,  as  a 
general  rule,  be  removed.  When  very  many  tumours  are 
present  (ten  or  twenty)  it  is  not  customary  to  interfere  with 
them,  for  when  multiple  they  rarely  attain  uncomfortable  or 
dangerous  proportions.  It  occasionally  happens  with  'multiple 
(and  also  with  solitary)  lipomas,  that  one  or  other  becomes 
irritated  by  some  part  of  the  dress,  such  as  petticoat  bands, 
braces,  etc.,  or  in  some  particular  employment  followed  by 
the  individual.     Such  tumours  should  invariably  be  removed. 

The  removal  of  a  subcutaneous  lipoma  is  one  of  the 
simplest  proceedings  in  surgery,  but  the  extirpation  of  a 
large  subperitoneal  fatty  tumour  is  often  attended  with 
difficulty  and  grave  danger. 

Berger,  "  Calcul  salivaire  et  Hypertrophie  de  la  Boule  graisseuse  de  Bichat." 

—  Gaz.  des  Hdp.,  1883,  Ivi.  1041. 
Bland-Sutton,  J„  "  On  a  Fatty  Tumour  of  the  Ascending  Colon  ;  Enterectomy ; 

Recovery."— iajice^,  1900,  i.  1437, 

Bonnot,  E.,  "  The  Interscapular  Gland."— /(wm.  of  Anat.  and  Phys,,  xliii.  43. 

Cooper,  Sir  Astley,  "  Case  of  a  Large  Adipose  Tumour  successfully  extir- 
pated."— Med.-Chir.  Trans.,  1821,  xi.  440. 

Edmunds,  W.,  "  Fatty  Tumour  from  the  lA^."— Trans.  Path.  Soc,  1893,  xliv. 
151. 

Eve,  F.  S.,  "Large  Congenital  Lipoma  situated  between  the  Abdominal 
Muscles  and  Vasciie."— Trans.  Path.  Soc,  1886,  xxxix.  295. 

Forster,  J.  Cooper,  "  Fibro-Fatty  Tumour  of  the  Abdomen,  weighing  fifty-five 
pounds." — Trans.  Path.  Soc,  1868,  xix.  246. 


EEFEEENGES  25 

Gabryszewski,  A.,  "Ueber  Lipome  des  Samenstranges." — Deutsche  Zeitschr.f. 

Chir.,  1898,  xlvii.  317. 
Gay,  J.,  "  Fatty  Tumour  on  Sole  of  WooL"— Trans.  Path.  Sog.,  1863,  xiv.  243. 
Gowers,   W.  R.,   "Myo-Lipoma  of  Spinal  Cord." — Trans.  Path.    Soc.,  1876, 

xxvii.  19. 
Gussenbauer,   C,  "Ein  Beitrag   zur  Kenntaiss  der  subpleuralen  Lipome." — 

Arck.f.  lilin.  Chir.,  1892,  xliii.  822. 
Hatai,  S.  "On  the  Presence  in  Human  Embryos  of  an  Interscapular  Gland 

corresponding  to  the  so-called  Hibernating  Gland  of  Lower  Mammals." 

— Anat.  Anteiger,  xxi.  369. 
Holt,  B.,  "Fatty  Pendulous  Tumour  of  the  Pharynx  and  Larynx." — Trans. 

Path.  Soc.,  1854,  v.  123. 
Hutchinson,  J.,  jun.,  "  Lipomata   in    Hernial   Regions." — Trans.   Path.  Soc, 

1886,  xxxvii.  451. 
Hutchinson,   J.,  jun.,  "  Fatty   Hernise   in  Linea   Alba." — Trans.  Path.  Soc, 

1888,  xxxix.  451. 
Knaggs,   R.   Lawford,    "  Enteric   Intussusception    caused   by    an    Intestinal 

Lipoma  ;    Laparotomy  ;    Reduction  ;     Removal    of   Tumour  ;    Recovery. 

[Tv7o  Unusual  Cases  of  Intussusception.]  " — Lancet,  1900,  ii.  1573. 
Langemak,  "  Zur  Kasuistik  der  Darmlipome." — Beit.  %.  klin.  Chir.  (Bruns), 

1900,  xxviii.  247. 
Lebert,  "  Traite  d'Anatomie  pathologique,"  Plate  xvi..  Fig.  11,  t.  1,  128. 
Lockwood,  C.  B.,  "  Congenital  Fatty  Tumours  of  Sole  of  the  Foot,  and  Fatty 

Tumour  from  Palm  of  Hand." — Trans.  Path.  Soc,  1886,  xxxvii.  450. 

Obre,  H.,  "Deposit   of   Fat   within  the   Cervical   Portion   of  the  Vertebral 

Canal."— Tm«s.  Path.  Soc,  1850-51,  iii.  248. 
Parona,  F.,  "  Caso  di  Lipoma  all'  Ovaja  ed  Ovidutto  di  Destra." — An7i,.  di 

Ostet.,  Milano,  1891,  xiii.  103,  pi.  1. 
Pick,  T.  Pickering,    "  Enormous   Fatty   Tumour   of  the  Abdomen." — Trans. 

Path.  Soc,  1869,  xx.  337. 
Pupovac,  D.,  "  Ueber  seltene  Localisationen  von  Fettgeschwiilsten." —  Wie7i. 

Idin.  JFooh.,  1899,  xii.  41. 
Ranke,  "  Ein  Saugpolster  in  der  menschlichen  Backe." — Virchow's  Arch.  /. 

path.  Anat.,  1884,  xcvii.  527. 
Shattock,  S.  G.,  "  On  Normal  Tumour- like  Formations  of  Fat  in  Man  and  the 

Lower  Animals." — Proc  Boy.  Soc  Med.,  Path.  Sec,  1909,  207. 
Shattock,  S.  G.,  "  A  Large  Laryngeal  Lipoma  of  the  Epiglottis  and  Base  of  the 

Tongue,  with  a   collection   of  examples  of  Submucous  Lipomata  of  the 

Intestines  and  Larynx." — Ibid.,  285. 
Smith,  T.,  "A  Fibro-Muscular  Polypus  growing  from  the  Uterus,  and  contain- 
ing a   Cyst    and  a   Small    Fatty    Tumour." — Trans.    Path.    Soc,    1861, 

xii.  148. 
Steinheil,  "Ueber  Lipome  der  Hand  und  Finger." — Beit.  z.  Idin.  Chir.,  1891, 

vii.  605. 

Stetten,  D.,  "The  Submucous  Lipoma  of  the  Gastro-Intestinal  Tract." — 
Surgery,  Gynceeology  and  Otstetrics,  Chicago,  1909,  ix.  156. 

Treves,  Sir  Frederick,  "A  Case  of  Lipoma  of  the  Broad  Ligament." — Trans. 
Clin.  Soc,  1893,  xxvi,  101. 


CHAPTER   II 

CHONDROMAS    (CARTILAGE  TUMOURS) 

A  CHONDROMA  (or  enchondroma)  is  a  tumour  composed  of 
hyaline  cartilage.  Its  tissue  resembles  histologically  the 
bluish  translucent  cartilage  of  an  epiphysis.  This  genus 
contains  three  species — (1)  chondroma,  (2)  ecchondrosis, 
(3)  loose  cartilages  in  joints. 

1.  Chondromas. — This  species  in  its  most  typical  con- 
ditions occurs  in  long  bones,  and,  as  a  rule,  in  relation 
with  the  epiphysial  cartilages  ;  hence  this  tumour  is  most 
frequently  observed  in  children  and  young  adults.  A  single 
tumour  may  be  present,  but  frequently  many  grow  con- 
currently, especially  on  the  long  bones  of  the  hand  and 
feet.  An  exceptional  example  is  represented  in  Fig.  12, 
but  similar  conditions  have  been  described  by  Kast, 
Steudel,  and  Recklinghausen. 

Chondromas  are  always  encapsuled,  and  often  form 
deep  hollows  in  the  bones  from  which  they  arise.  They 
are  painless,  grow  slowly,  and  are  firm  to  the  touch.  Fre- 
quently they  undergo  mucoid  degeneration,  then  the 
softened  area  gives  rise  to  fluctuation.  This  serves  to 
distinguish  them  from  osteomas,  with  which  they  are  apt 
to  be  confounded  clinically.  A  chondroma  frequently 
calcifies,  and  sometimes  ossifies  (Fig.  13). 

The  frequency  of  chondromas  in  those  who  suffered 
from  rickets  in  early  life  may  be  due,  as  Virchow  thought 
probable,  to  the  existence  of  untransformed  pieces  of 
cartilage  acting  the  part  of  tumour-germs.  Such  remnants 
of  unossified  cartilage  are  not  difficult  of  demonstration  in 
rickety  bones  (Fig.  14). 

A  chondroma  is  a  very  benign  tumour,  and  even  when 
it  grows  into  the  skull  may  require  a  long  time  to  destroy 
life,   as    a    very    rernarkable  specimen  in   the    museum   of 

26 


CHONDROMAS 


27 


St.  George's  Hospital  proves.  It  is  a  cartilage-tumonr 
which  arose  in  the  mesethmoid  of  a  young  woman,  and 
then  filled  the  nasal  fossse  and  occupied  both  orbits,  and 
dislocated  the  globes  outwards ;  it  filled  the  antra, 
expanded  the  nasal  bones,  invaded  the  spheno-maxillary 
fossse   and   formed   a  large   mound  in  the  anterior   fossa  of 


#v\ 


Fig.  12. — MultiiDle  diondromas.     (The  lad  was  stunted  from  rickets.) 

the  skull,  and  almost  reached  the  roof  of  the  cranium. 
Its  disruptive  effects  upon  the  facial  bones  were  very  extra- 
ordinary. In  spite  of  this,  the  patient's  health  was  but 
little  disturbed ;  she  had  no  loss  of  intellect,  and,  it  is 
believed,  no  paralysis.  The  course  of  the  disease  from  its 
origin  till  the  patient  died  was  about  six  years. 

Although  a  chondroma  invading  the  skull  may  require 
(as   in  the  example  just  described)  years  to  kill  a  patient 


28 


CONNECTIVE-  TI88  UE    TUMO UBS 


there  is  a  situation  in  which  in  certain  circumstances  it 
will  cause  great  distress  and  death — namely,  in  the  pelvis. 
The  effects  which  such  tumours  produce  on  the  pelvic 
viscera  are  in  some  cases  very  remarkable.  The  specimen 
represented  in  section  in  Fig.  13  was  obtained  from  a 
woman  21  years  of  age  who,  with  a  large  chondroma  in 
her  pelvis,   became   pregnant.      Delivery   by   natural   means 


Fig.  13. — Pelvis  occupied  by  a  large,  partially  ossified  chondroma,  shown  in  sagittal 
section  :  from  a  woman  21  years  of  age  who  died  from  hysterectomy  performed 
for  obstructed  labour  at  term.   (Museum   of  University  College,  Zondon.) 

being  impossible,  hysterectomy  was  performed ;  but  the 
patient  died.  Apart  from  obstructing  labour,  the  tumour 
had  pressed  on.  the  ureters  and  produced  dilatation  of  both 
of  them  and  sacculation  of  the  kidneys.  This  unfortunate 
woman  was  known  to  have  a  tumour  in  her  pelvis  seven 
years  previously  to  her  tragic   death. 

Pathological  cartilage  occurs  in  spindle-celled  sarcomas 
(p.  55) ;  also  in  tumours  of  the  salivary  glands,  especially  the 
parotid.    Cartilage-containing  tumours  grow  in  the  lachrymal 


CHONDROMAS 


29 


gland,  in  tendon  sheaths  (Walker),  in  the  testis,  and  in 
the  breast. 

2.  Ecchondroses. — These  may  be  defined  as  small  local 
overgrowths  of  cartilage.  They  are  best  studied  along  the 
edges  of  articular  cartilages,  the  laryngeal  cartilages,  and 
the  triangular  cartilage   of  the  nose. 

Ecchondroses  are  especially  common  in  the  knee-joint, 
and  often  in  association  with  the  condition  termed  rheu- 
matoid arthritis.  They  are  frequent  in  the  joints  of  indi- 
viduals who  have  passed  the  meridian  of  life,  and  they  occur 
as  small  projecting  prominences  along  the  margins  of  the 
articular  cartilage.     Often  the  edge  of  the  cartilage  is  pro- 


Fig.  14. — Condyles  and  epiphysial  Hne  of  a  rickety  femur,  -with  a  cartilage 
island.     {Museum  of  the  Middlesex  Hospital!) 

duced  into  a  raised  prominent  lip,  the  regularity  of  which  is 
broken  here  and  there  by  a  sessile  or  a  pedunculated  nodule. 

When  these  nodules  are  examined,  many  of  them 
present  on  their  outer  surface  a  convex  outline,  but  on 
the  inner  aspect — that  looking  towards  the  joint — they  are 
concave,  the  concavity  being  produced  by  friction  during 
the  movements  of  the  joint,  or  by  pressure  when  the 
parts  are  at  rest.  Occasionally  erosion  of  the  ecchondrosis 
may  extend  so  deeply  that  by  some  extra  movement  ot 
the  joint  the  pedicle  is  broken,  and  the  detached  nodule 
either  falls  as  a  loose  body  into  the  joint-cavity,  or  it 
may  be  retained  in  position  by  its  attachments  to  the 
fibrous  structures  of  the  articulation. 

Laryngeal     ecchondroses    are     by    no    means    common; 


30  G01!TNEGTIVE-T188UB    TUMOURS 

they  grow  from  the  thyroid,  cricoid,  and  occasionally  the 
arytenoid  cartilages,  but  very  rarely  from  the  semi-rings 
of  the  trachea.  Paul  Bruns  collected  fourteen  cases  of 
laryngeal  chondromas ;  of  these,  eight  sprang  from  the 
cricoid,  four  from  the  thyroid,  one  from  the  arytenoid,  and 
one  from  the  epiglottis.  Most  of  the  ecchondroses  of  the 
cricoid  cartilage  sprang  from  the  broad  posterior  plate. 
'  In  many  of  the  cases  the  inner  and  outer  surfaces  of  the 
cricoid  were  involved,  so  that  the  tumour  encroached 
upon  the  cavity  of  the  larynx.  Ecchondroses  vary  greatly 
in  size ;  some  are  scarcely  larger  than  a  pea,  others  may 
be  ■  as  big  as  a  walnut.  Morell  Mackenzie  described  an 
example  growing  from  the  cricoid  which  attained  the  size 
of  a  bantam's  egg ;  in  this  instance  the  tumour  extended 
downwards  in  front  of  the  trachea.  Small  ecchondroses 
growing  from  the  inner  surfaces  of  the  laryngeal  cartilages 
are  more  dangerous  than  the  larger  examples  springing 
from  their  outer  surfaces.  Ecchondroses,  when  projecting 
into  the  larynx,  are  covered  with  its  mucous  membrane ; 
they  may  be  smooth  or  tuberculated,  round  or  conical.  In 
exceptional  cases  the  overl3dng  mucous  membrane  has  been 
found  ulcerated.  Chondromas,  when  they  project  into 
the  larynx,  produce  stridor  and  difficulty  in  breathing,  and 
sometimes  interfere  with  the  movements  of  the  vocal  cords. 
When  the  tumours  only  involve  the  outer  surfaces  of  the 
laryngeal  cartilages  they  do  not,  as  a  rule,  cause  any 
inconvenience  unless  they   are  exceptionally  large. 

Small  outgrowths  from  the  triangular  cartilage  of  the 
nose  are  by  no  means  uncommon ;  they  never  attain  a 
large  size,  and  are  always  sessile.  It  is  difficult  to  imagine 
that  ecchondroses  of  the  nasal  cartilage  could  be  a  source 
of  much  inconvenience,  but  surgeons  who  study  diseases  of 
the  nasal  passages  view  them  with  disfavour. 

3.  Loose  cartilages. — Bodies  of  various  kinds  are  found 
loose  in  the  cavities  of  large  joints,  but  those  to  be  considered 
under  the  head  of  chondromas,  in  addition  to  detached 
ecchondroses,  are  pieces  of  hyaline  cartilage  found  hanging  in 
the  joint  by  narrow  pedicles,  or  occupying  depressions  in  the 
bone  from  which  they  are  occasionally  dislodged.  Structurally 
they  are  composed  of  hyaline  cartilage,  and  assume  various 


CHONDROMAS  31 

forms.  Some  appear' as  flat  discs,  others  are  ovoid  ;  they  may 
be  perfectly  smooth,  or  present  an  irregular,  worm-eaten  ap- 
pearance; and  the  majority  are  impregnated  with  calcareous 
particles.  It  is  a  remarkable  fact  that  in  many  instances  in 
which  a  loose  cartilage  has  been  found  in  one  joint,  a  body 
identical  in  size  and  shape  has  been  found  in  the  corresponding 
joint  of  the  opposite  limb  (Bowlby,  Glutton,  Weichselbaum). 
Loose  cartilages  may  be  single  or  multiple :  several  hundred 
may  exist  in  one  joint,  and  vary  in  size  from  a  rape-seed  to 
an  almond. 

The  origin  of  these  cartilages  is  interesting.  In  large  joints, 
such  as  those  of  the  hip,  knee,  or  shoulder,  it  is  easy  to  demon- 
strate, in  the  recesses  of  the  joint,  near  the  spot  where  the 
synovial  membrane  becomes  continuous  with  the  margin  of 
the  articular  cartilage,  villous-like  processes  of  the  synovial 
membrane  projecting  into  the  joint.  Under  certain  con- 
ditions, especially  that  known  as  rheumatoid  arthritis,  these 
villi  become  greatly  enlarged  and  increase  in  number  until  the 
whole  synovial  membrane  may  be  so  covered  with  them  as 
to  become  quite  velvety  in  appearance.  Structurally,  these 
synovial  villi  consist  of  a  reduplication  of  the  serous  mem- 
brane, and  contain  tufts  of  capillaries.  As  they  enlarge,  some 
of  them  undergo  chonclrification,  and  this  change  may  take 
place  so  extensively  that  a  villous  process  is  entirely  converted 
into  hyaline  cartilage,  which  becomes  the  matrix  for  a  deposit 
of  lime  salts.  As  these  nodules  of  cartilage  are  merely  sus- 
tained by  narrow  pedicles,  the  nodules  may  be  detached 
either  by  their  mere  weight,  by  undue  movement  of  the  joint, 
or  from  axial  rotation,  and,  tumbling  into  the  joint,  give  rise 
to  all  the  inconveniences  characteristic  of  a  loose  body. 
Specimens  occasionally  come  to  hand  in  which  cartilaginous 
bodies  of  this  description  may  be  found  sessile  among  the 
fringes,  or  hanging  on  good  pedicles,  or  with  stalks  so  thin 
that  they  appear  to  be  on  the  eve  of  detachment. 

Occasionally  these  overgrown  synovial  villi,  instead  of 
chondrifying,  are  converted  into  oval  bodies  which,  on  micro- 
scopical examination,  present  a  central  cavity  surrounded  by  a 
laminated  structureless  substance.  To  the  naked  eye  many 
of  these  oval  bodies  resemble  cartilage,  and  it  is  only  on 
microscopical  examination  that  it  is  possible  to  distinguish 


32  CONNECTIVE-TISSUE    TUMOURS 

between  them  ;  many  are  infiltrated  with  calcareous  granules. 
These  oval  bodies  are  present,  in  some  cases,  in  great  number. 
On  one  occasion  I  counted  1,532  which  were  removed  from 
the  shoulder-joint.  Bodies  of  this  description  occur  not  only 
in  joints,  but  in  compound  ganglia  and  bursse. 

A  good  physiological  type  for  the  loose  cartilaginous  bodies 
which  infest  joints  is  furnished  by  the  temporo-mandibular 
joint  of  the  skate.  A  recess  communicating  with  this  articular 
cavity  usually  contains  a  collection  of  smooth  cartilaginous 
bodies,  in  contour  and  size  like  melon-seeds. 

Treatment. — The  operative  treatment  of  chondromas  has 
been  greatly  simplified  since  surgeons  have  appreciated  the 
fact  that  these  tumours,  when  growing  in  relation  with  bones, 
are  distinctly  encapsuled.  Now,  when  it  is  necessary  to  inter- 
fere with  a  chondroma,  even  in  cases  where  several  tumours 
are  present,  it  has  become  customary  to  incise  the  capsule 
and  shell  out  the  cartilage.  In  most  instances  this  simple 
method  is  successful.  Exceptionally,  however,  cases  come 
under  observation  which  demand  more  serious  measures. 
When  the  cartilage-tumours  are  very  numerous  on  the  bones 
of  the  hand,  the  fingers  are  so  crippled  and  useless  that 
amputation  becomes  necessary.  Fortunately,  such  severe 
treatment  is  very  rarely  needed. 

In  the  case  of  loose  bodies  in  joints  it  is  the  usual  practice, 
when  the  pieces  of  cartilage  are  in  the  habit  of  getting  between 
the  opposed  surfaces  of  the  joint,  to  open  the  synovial  cavity 
and  remove  the  loose  body  or  bodies.  When  this  manoeuvre 
is  conducted  with  proper  care  it  is  highly  successful.  When 
the  loose  body  is  lodged  in  a  sacculus,  it  is  in  a  measure  isolated 
from  the  general  cavity  of  the  joint,  and  does  not  call  for  inter- 
ference. The  smaller  bodies,  which,  like  mice,  slip  in  and  out 
of  the  recesses  of  a  complex  joint,  are  more  likely  to  give  trouble 
than  those  larger  pieces  of  cartilage,  sometimes  as  big  as  chest- 
nuts, which  the  patients  can  grasp  with  their  fingers  and  push 
in  and  out  of  the  great  cul-de-sac  above  the  patella  almost  as 
readily  as  a  marble  may  be  manipulated  under  a  tablecloth. 

Bowlby,  A.  A.,  "Rare  Forms  of  Loose  Bodies  from  the  Knee-Joints." — Trans. 

Path.  Soc,  1888,  xxxix.  281. 
Bruus,  Paul,  "  Enchondrom    des    Kehlkopfs." — Beit.  z.  Jdin.   Cliir.   (Bruns), 

1888,  iii.  347. 


BEFEBENGES  33 

Glutton,  H.  H.,  "Symmetrical  Loose  Bodies  from  Two  Knee-Joints." — Trails. 

Path.  Soc„  1888,  xxxix.  284. 
Kast  und  von  Recklinghausen,  "  Ein  Fall  von  Enchondrom  mit  ungevvohnlicher 

Multiplication." — Virchow's  Arch./,  imtli.  Anat.,  1889,  cxviii.  1. 
Mackenzie,  Morell,  "  Fibroid  Degerieration  of  the  Cartilages  of  the  Larynx." 

—Trans.  Path.  Soc,  1870,  xxi.  58. 
Steudel,  "  Multiple  Encliondrome  der  Knochen   in  Verbindung  mit  venosen 

Angiomen    der    Weichteile." — Beit,    z.   hlin.    Chlr.    (Bruns),    1892,  viii. 

503. 
Walker,  R.  R.,  '•  A  Case  of  Endochondroma  of  the  Tendon-Sheath  of  a  Finger." 

—  Clin.  Jonrn.,  1908,  240. 
Weichselbaum,   A.,    "Zur  Genesis  der  Gelenkkorper." — Virchow's  Arch.  f. 

path.  Anat.,  1873,  Ivii.  127. 


CHAPTER  III 

OSTEOMAS    (OSSEOUS   TUMOURS) 

An  osteoma  may  be  defined  as  an  ossifying  chondroma.  The 
genus  contains  two  species:  1,  compact  osteomas;  2,  can- 
cellous osteomas. 

1.  Compact  osteomas. — These  occur  as   sessile   tumours 
on  the  parietal  and  frontal  bones  ;  in  the  frontal  sinus,  roof  of 


Fig.  15. — Osteoma  of  mandible.     {St.  George'' s  Hospital  JItcseicm.) 

the  orbit,  walls  of  the  external  auditory  meatus,  mastoid 
process,  and  angle  of  the  mandible  (Fig.  15).  They  are  com- 
posed of  tissue  as  dense  and  as  hard  as  ivory,  and  are  fre- 
quently called  "ivory  exostoses."  Those  which  arise  in  the 
frontal  sinus  and  orbit  are  very  remarkable  tumours,  and  may 
attain  large  proportions  (Figs.  16,  17,  and  18).  Many  large 
tumours  removed  from  the  maxilla  and  described  as  exostoses 
were  large  odontomes  (see  Chapter  xxi.). 

Large  osteomas  of  the  facial  bones  sometimes  produce 
hideous  deformity,  and  when  they  grow  from  the  bones 
forming  the  rim  of  the  orbit  occasionally  destroy  the  eyeball. 
The  clinical  histories  of  some  of  these  cases  are  very  remark- 

34 


OSTEOMAS 


35 


able  ;  for  example,  a  man  came  under  Lediard's  observation 
with  a  large  osteoma  protruding  from  the  orbit  (Fig.  16).  The 
patient,  a  sailor,  stated  that  the  tumour  was  noticed  at  birth, 
when  it  seemed  scarcely  larger  than  a  pea  ;  it  slowly  increased 
in  size,  and  when  he  was  9  years  old  it  destroyed  the  eye- 
ball. When  he  was  25  years  of  age  the  skin  of  the  eyelid 
sloughed.  Eight  years  later  the  tumour  fell  out  of  the  orbit. 
The  spontaneous  detachment  of  an  osteoma  in  this  way  is 


Fig.  16. — Sailor  with  a  large  osteoma  growing  from  the  orbit.     (From  a  icater- 
colonr  sketch  in  the  Iltiseum  of  tlie  Royal  College  of  Surgeons.) 

due  to  necrosis  of  the  tumour,  and  is  parallel  to  the  shedding 
of  the  antlers  in  the  stag.  Osteomas  of  the  orbit  which  have 
resisted  the  efforts  of  surgeons  to  remove  them  have,  years 
after  such  operations,  fallen  of  their  own  accord. 

The  large  and  exceedingly  hard  ivory-like  tumours  which 
grow  in  the  frontal  sinuses  are  uncommon.  An  admirable 
example  figured  by  Baillie,  and  preserved  in  the  museum 
of  the  Royal  College  of  Surgeons,  is  unfortunately  without 
history  (Figs.  17  and  18). 

Osteomas  of  this  kind  arise  occasionally  in  the  frontal 
sinuses  of  oxen,  and  form  huge  irregular  lobulated  masses, 


36 


C0NNBGTIVE-TI88UE    TUMOURS 


sometimes   weighing   as   much   as   sixteen   pounds.     Similar 
tumours    grow   from   the   petrosal   and   encroach   upon    the 


Fig.  17. — Osteoma  in  the  left  frontal  sinus  (anterior  view). 

cranial  cavity  ;  some  of  these  have  been  reported  in  veterinary 
literature  as  ossified  brains  ! 

Osteomas  at  the  margins  of  the  external  auditory  meatus 
have  been  especially  studied  because  they  are  apt  to  obstruct 
the   meatus   and  cause   deafness ;   when  both   meatuses  are 


Fig.  18. — Osteoma  in  the  left  frontal  sinus  (seen  from  below).     {Mksckiii  of 
the  Royal  College  of  Surgeons.) 

affected — and  this  is  not  rare — absolute  deafness  may  result. 
It  is  a  curious  fact  that  osteomas  at  the  margin  of  the  audi- 
tory meatus  have  been  observed  in  many  different  races  of 


OSTEOMAS  37 

men.  Professor  Sir  William  Turner  has  drawn  attention  to 
observations  of  Seligmann,  VVelcker,  and  Barnard  Davis,  and 
added  some  of  his  own,  concerning  the  presence  of  such 
exostoses  in  certain  deformed  skulls  described  as  Titicaca's 
Huanaka's,  and  Aymara's.  Also  in  skulls  from  the  Marquesas 
Islands,  Sandwich  Islands,  Chatham  Island,  and  New  Zealand. 
It  is  not  surprising  that  osteomas  should  arise  from  the 
walls  of  the  external  auditory  meatus  when  we  remember 
the  number  of  centres  by  which  the  periotic  cartilage  is 
transformed  into  bone,  and  the  various  ossific  elements  that 
come  into  relation  with  each  other  at  this  meatus. 

2.  Cancellous  osteomas. — These  tumours  in  structure 
resemble  the  cancellous  tissue  of  bone,  and  are  soft  in  com- 
parison with  the  preceding  species.  They  usually  possess  a 
thick  covering  of  hyaline  cartilage,  and  when  growing  at  the 
distal  end  of  the  radius,  or  tibia,  present  a  series  of  deep 
channels  for  the  passage  of  tendons.  Occasionally  an  osteoma 
is  pedunculated ;  more  frequently  it  has  a  broad  base.  Osteo- 
mas, whether  sessile  or  stalked,  usually  grow  slowly,  but  in 
the  course  of  years  they  sometimes  attain  large  proportions. 
They  are  innocent  tumours,  but  occasionally  imperil  life  by 
mechanically  interfering  with  the  function  of  vital  organs. 
Reid  described  a  case  in  which  an  osteoma  grew  from  the 
posterior  surface  of  the  odontoid  process  and  projected  into 
the  neural  canal  to  the  extent  of  8  mm.,  compressing  the 
spinal  cord  with  fatal  effect.  Although  in  themselves  pain- 
less, osteomas  sometimes  induce  pain  by  pressing  on  nerve 
trunks  in  their  vicinity.  Often  an  osteoma  is  quite  harmless 
(Fig.  19). 

Multiple  cartilage-tipped  osteomas  are  most  frequent  on 
the  long  bones  of  the  arms  and  forearms,  thighs  and  legs,  and 
are  often  congenital,  hereditary,  and;  so  far  as  position  is  con- 
cerned, fairly  symmetrical.  Otto  Weber  recorded  a  remark- 
able case  of  numerous  symmetrical  exostoses  of  the  long 
bones  of  the  upper  and  lower  limbs,  the  ribs,  and  scapula 
in  a  man  25  years  old.  A  chondro-sarcoma  arose  in  the  right 
hip-bone  and  attained  enormous  proportions.  It  perforated 
the  left  external  iliac  vein,  and  pieces  of  the  tumour,  detached 
as  emboli,  lodged  in  the  pulmonary  artery. 

Exostoses. — It  has  been  customary  to  describe   all   kinds 


38 


CONNECTIVE-TISSUE    TUMOURS 


of  tumours  composed  of  bone,  or  bone-like  tissue,  under  the 
name  of  exostoses.  The  term  exostosis  should  be  limited  to 
irregular  outgrowths  of  bone  to  which  the  term  tumour  is  not 
in  any  sense  applicable.  The  various  bony  outgrowths  classed 
as  exostoses  fall  into  three  groups  : — 

1.  Ossification  of  tendons  at  their  attachments. 

2.  The  subungual  exostosis. 

3.  Calcification  of  inflammatory  exudations. 

1.  Exostoses  formed   hy  ossification  of  tendons  at   their 
attachments. — The  lono-  bones  of  a  child  at  birth  are  smooth 


Fig.  19. — Cancellous  osteoma  of  the  scapula.     {HCuseuni  of  the  Eoyal  College  of 

Siirgeons.) 

in  outline  and  almost  cylindrical  in  shape ;  the  periosteum  is 
relatively  thick,  and  gives  attachment  to  the  muscles.  On  ex- 
amination of  the  long  bones  of  an  adult  muscular  man  their 
shafts  are  found  to  be  irregular,  and  present  many  asperities, 
such  as  the  linea  aspera,  gluteal  ridge  (sometimes  called  the 
third  trochanter),  oblique  lines,  and  the  like.  These  ridges 
and  lines,  in  the  majority  of  instances,  are  the  ossified  inser- 
tions  of  muscles;     occasionally  they  are  so  pronounced  as 


OSTEOMAS 


39 


to  be  appreciable  through  the  soft  structures,  and  are  then 
described  clinically  as  exostoses.  The  two  most  frequent 
examples  of  this  form  of  exostosis  are  the  adductor  tubercle  of 
the  femur  and  the  tubercle  on  the  first  rib  at  the  insertion  of 
the  scalenus  anticus.  Probably  the  most  common  exostosis 
is  that  which  occurs  in  the  tendon  of  insertion  of  the  adduc- 
tor magnus  (Fig.  20) :  it  usually  assumes  the  form  of  a  broad 
ledge  of  bone  ;  exceptionally  it  is  stalked,  and  in  rare  cases 
surmounted  by  a  bursa ;    the  walls  of  such  burste  are  now 


Fig.  20. — Exostosis  of  the  femur,  produced  by  ossification  of  the  tendon  of  the 
adductor  magnus.      {Museum  of  the  Royal  College  of  Surgeons.) 


and  then  furnished  with  villi,  and  loose  bodies  have  been 
found  in  them  (Orlov/  and  Riethus).  Care  must  be  taken 
not  to  confound  a  su23racondyloid  process  of  the  humerus,  or 
the  occasional  third  trochanter  of  the  femur,  with  exostoses. 

Localized  outgrowths  are  very  common  on  the  facial 
bones,  especially  the  nasal  processes  of  the  maxillfe,  where 
they  may  be  unilateral  or  bilateral  (Fig.  21).  The  cause 
of  these  exostoses  is  obscure.  Small  irregular  osseous  pro- 
minences are  fairly  frequent  along  the  alveolar  borders  of 
the  maxilla  and  mandible. 


40 


CONNECTIVE- TI8S UE    T UM 0 UBS 


Exostoses  of  the  maxilla  have  been  observed  in  natives 
of  the  West  Coast   of  Africa,   and  in   all   probability  have 


Fig.  21. — Symmetrical  exostoses  of  the  nasal  processes  of  the  maxillag. 
{After  Hutchinson.) 

originated  the  myth  of  the  existence  of  horned  men  in 
this  region.  Interesting  particulars  relating  to  this  ques- 
tion are  furnished  by  Macalister  and  by  Lamprej^     Strachan 


Fig.  22. — So-called  horned  men  of  the  Ivory  Coast.     {Maclaud.) 

has  observed  them  in  the  West  Indian  negro,  and  Dr. 
Maclaud,  of  the  French  Navy,  met  with  them  frequently 
in  the  natives  of  certain  villages  on  the  Ivory  Coast,  where 


OSTEOMAS  41 

the  disease  is  known  as  "goundou."  These  bony  swelHngs 
may  become  so  large  as  to  obscure  the  patient's  vision,  and 
in  order  to  see  over  the  top  of  them  he  is  obhged  to  bend 
his  head  down. 

2.  The  suhungiial  exostosis  is  a  troublesome  outgrowth 
from  the  ungual  phalanx  of  the  big  toe;  it  makes  its  way 
through  the  bed  of  the  nail,  and  peers  out  between  the 
nail  and  the  skin  at  the  tip  of  the  toe,  near  the  inner  side 
(Fig.  23) ;  its  appearance  is  so  characteristic  that  it  only 
requires  to  be  once  seen  to  be  appre- 
ciated readily.  It  is  rarely  bigger  than 
a  cherry-stone. 

When  the  soft  investing  tissues  are 
removed,  the  tumour  appears  as  a  low 
prominence  of  cancellous  bone  jutting 
from  the  dorsal  surface  of  the  terminal 
phalanx.  These  outgrowths  are  probably 
due  to   the   pressure   of  ill-fitting  boots, 

J      1        ij    r  ^     J  -a  ^ig-  23.-Big  toe  with  a 

and  should  be  ranked  among  milamma-       subungual  exostosis, 
tory  productions. 

3.  Exostoses  due  to  calcification  of  infiaminatory  exucla,- 
tions  scarcely  require  consideration  in  this  work;  there  is 
reason  to  believe  that  some  of  the  cases  described  as 
multiple  exostoses  were  really  examples  of  the  strange  and 
rare  disease  known  as  "  myositis  ossificans." 

Bony  tumours  are  of  fairly  frequent  occurrence  in  all 
vertebrates.  Paul  Gervais  has  published  descriptions  of 
many  interesting  specimens  from  fish.  Perhaps  the  most 
striking  example  is  furnished  by  the  skeleton  of  the  fish 
ch^etodon,  in  Avhich  some  of  the  bones  are  furnished  with 
rounded  bony  tumours.  The  museum  of  the  Royal  College 
of  Surgeons  contains  many  loose  bones  with  tumours, 
as  well  as  the  skeleton  of  the  original  fish  sent  by 
William  Bell  to  John  Hunter  (Fig.  24).  Single  bones  of 
chaatodon  are  common  in  osteological  collections.  Cuvier 
explained  this  by  stating  that  they  were  brought  home  by 
travellers  who  had  eaten  the  fish.  On  section  the  outline 
of  the  ray  can  be  seen  running  through  the  tumour. 

Clinical  characters.  —  Osteomas  are  easily  recognized 
on    account     of    their    extreme    hardness,     and    by    being 


42  CONNECTIVE-TISSUE    TVMOtfRS 

localized  to  bones :  tliey  rarely  cause  pain,  except  when 
growing  in  the  vicinity  of  and  pressing  upon  the  trunks 
of  nerves.  Osteomas  growing  from  the  Avails  of  the 
auditory  meatus  will  occasionally  interfere  with  hearing, 
and  if  they  are  bilateral,  and  completely  block  both  meatuses, 
produce  total  deafness  (Field).  Large  osteomas  of  the  orbit 
and  frontal  bone  distort  the  eyeball,  and  produce  hideous  de- 


Fig.  24. — Bell's  specimen  of  chsetoclon  with  its  tumours  and  large  occipital  crest. 

formity.  In  determining  the  characters  and  mode  of  attach- 
ment of  an  osteoma,  especially  in  the  limbs,  the  X-rays 
render  valuable  assistance. 

Treatment. — Osteomas,  unless  they  interfere  with  nerves 
or  with  the  movement  of  joints,  or,  as  in  the  case  of  the 
facial  bones,  produce  deformity  or  deafness,  are  rarely 
interfered  with.  In  a  patient  under  the  writer's  care, 
with  a  large  intrapelvic  osteoma,  a  process  of  the  tumour 
pressed  upon  the  great  sciatic  nerve  as  it  issued  from  the 
pelvis  :  this  offending  process  was  exposed  through  an  in- 
cision in  the  buttock,  and  removed  by  means  of  a  chisel 
and  mallet.  Pedunculated  osteomas  may  be  easily  removed 
with  the  help  of  stout  forceps.  The  removal  of  an  ivory- 
osteoma  sometimes  requires  the  most  persevering  efforts 
of  the  surgeon,  aided  by  the  best  surgical  cutlery.  Exostoses 
near    joints    should   not    be    interfered    with,    unless    they 


OSTEOMAS 


43 


produce  great  inconvenience.  It  should  also  be  remembered, 
in  removing'  osteomas,  that  the  cancellous  tissue  of  the  bone 
from  which  they  grow  is  opened. 
Osseous  tumours  of  the 
cranial  bones  are  often  formid- 
able objects  for  the  surgeon  ; 
when  they  grow  from  the  roof 
of  the  orbit  or  the  frontal 
bone,  they  not  infrequently 
extend  as  deeply  into  the 
cranial  cavity  as  they  project 
beyond  it.  The  museum  of  St. 
George's  Hospital  contains  a 
small  ivory  tumour  which  grew 
on  the  frontal  bone  of  a  man. 
Keate  vainly  endeavoured  to 
remove  it  with  trephine,  saw, 
chisel,  and  mallet  for  nearly 
two  hours.  Potassa  fusa  and 
nitric  acid  were  applied  to  the 
base,  and  in  the  course  of  years 
the  tumour  dropped  off.  Sub- 
ungual exostoses  are  often  so 
painful  that  patients  are  glad 
to  have  them  removed. 


Fig.  25.  —  Thickened  occipital 
bone  of  a  fish,  with  a  man's 
face  artificially  carved  upon  it. 


Bell,  William,  "  Description  of  a  Species  of  Chffitodon,  called  by  the  Malays 

Ecan  Bonna."— P/n7.  Trans.,  1793,  Part  i.,  p.  7. 
Bland-Sutton,  J.,  "  On  an  Exostosis  from  a  Fish."— Trans.  Path.  Soc,  1888, 

xxxix.  472. 
Field,  G.  P.,  "Osseons  Tumours  of  the  Meatus." — "  Manual  of  Diseases  of  the 

Ear,"  London,  1893. 
Gervais,  Paul,  Journ.  clc  Zool.,  1875,  iv. 

Hutchinson,  Sir  J.,  "Illustrations  of  Clinical  Surgery,"  1878,  i.  11. 
Lamprey,    J.    J.,    "  Horned   Men   in   Africa :    Further   Particulars   of    their 

Existence."— 5H^.  Med.  Joiirn.,  1887,  ii.  1273. 
Lediard,  Trans.  OpUlial.  Soc,  1883,  iii.  23. 
Macalister,  A.,  "  Further  Evidence   as   to  the  Existence  of   Horned  Men   in 

Africa." — Proc.  Boy.  Irish  Acad.,  1883,  2nd  Series,  iii.  771. 
McGavin,  L.  H.,  "  A  Case  of  Multiple  Osteoma  associated  with  Chondro-Sarcoma 

of  the  W^hs."— Trans.  Path.  Soc,  1902,  liii.  356. 
Maclaud,    "  Goundou    or    Anaklire   (Gros   Nez)." — JBrit.   Med.   Journ.,    1895, 

i.  1217. 


44  CONNECTIVE-TISSUE    TUMOVUS 

Orlow,    L.   W.,   "Die   Exostosis   Bursata    unci    ihre    Entstehung-." — Devtsche 

Zdtschr.  f.  CMt.,  1891,  xxxi.  293. 
Held,  J.,  "  Case  of  Disease  of  the  Spinal  Cord,  from  an  Exostosis  of  the  Second 

Cervical  Vertebra." — Lond.    and   Edin.   Mooitldy   Journ.    of   Med.    Sci., 

1843,  iii.  194. 
Riethus,    0.,   "Exostosis  Bursata  mit  freien  Knorpelkorpern." — Beit.  z.  hUn. 

CUr.,  1903,  xxxvii.  639. 
Strachan,  H.,  "  Bony  Overgrowths  or  Exostoses  in  the  West  Indian  Negro."— 

Brit.  Mod.  Jmirn.,  1894,  i.  189. 
Turner,  Sir  William,  "  On  Exostoses  within  the  External  Auditory  Meatus." — 

Jovrn.  of  Anat.  and  Phys.,  1879,  xiii.  200. 
Weber,  Otto,  "  Zur  Geschichte   des   Enchondroms  namenlich  in  Bezag   auf 

dessen  hereditares  Vorkommen  und  secundare   Verbreitung   in   inneren 

Organen  darch  Embolie." — Virchow's  Arch.  f.  path.  Anat.,  1866,  xxxv. 

501. 


CHAPTEK    IV 
MYELOMAS 

A  MYELOMA  is  composed  of  tissue  identical  with  the  red  marrow 
of  young  bone.  These  tumours  were  formerly  called  myeloid 
sarcomas. 

The  genus  contains  a  single  species — myelomas.      These 


Fig.  26. — Microscopic  characters  of  a  myeloma  from  the  acromial  end  of  the  clavicle. 

tumours  arise  only  in  the  cancellous  tissue  of  bone.  When 
fresh  the  cut  surface  of  the  tumour  is  deep  red,  and  looks 
not  unlike  a  piece  of  fresh  liver,  and  is  very  vascular.  Micro- 
scopically, this  tissue  abounds  in  large  multinuclear  cells 
(giant  cells,  myeloplaques)  embedded  among  round  and 
spindle  cells.  The  giant  cells  are  so  numerous  as  to  consti- 
tute the  greater  proportion  of  the  tumour  (Fig.  26). 

The  distribution  of  myelomas  is  that  of  red  marrow,  but 
they  exhibit  a  striking  preference  for  certain  bones  ;  the  tibia 

45 


46  G0NNEGTIYE-TI8SVE    TUM0UB8 

is  tlie  favourite  bone  in  the  lower,  and  the  radius  in  the  upper 
Hrnb ;  whilst  so  far  as  the  bones  of  the  head  are  concerned, 
they  appear  to  be  peculiar  to  the  jaw-bones.  I  have  never 
seen  a  myeloma  in  a  vertebra.  In  the  long  bones  they  arise 
in  the  shaft  of  the  bone  immediately  adjacent  to  the  epi- 
physial junction  (Fig.  27) ;  and  if  the  epiphysial  cartilage  be 
present  it  would  seem  to  play  the  same  neutral  part  to  a 
myeloma  as  to  a  sarcoma. 


Fig.  27. — Lower  end  of  a  femiu-  in  longitudinal  section,  showing  a 
myeloma.     (From  a  girl  aged  16  years.) 

In  the  lower  limb  myelomas  have  been  observed  in  all 
the  large  bones,  but  they  show  a  decided  preference  for  the 
head  of  the  tibia. 

The  tibia  is  the  seat  of  a  myeloma  five  times  more  fre- 
quently than  any  other  long  bone,  and  it  is  five  times 
commoner  in  its  upper  than  in  the  lower  end  (Figs.  28,  29). 

In  the  radius  the  lower  end  is  the  favourite  site,  but 
myelomas  of  the  upper  end  are  not  unknown  (Figs.  30, 31). 


MYELOMAS 


47 


The  same  reversal  applies  to  the  fibula  and  the  ulna, 
myelomas  preferring  the  head  of  the  fibula,  but  the  lower 
end  of  the  ulna  ;  but  in  both  situations  they  are  very  rare. 

In  the  clavicle  several  examples  have  been  recorded  in 
the  sternal  end,  and  I  have  observed  one  at  the  acromial  end, 
an  excessively  rare  situation  (Fig.  32). 

In  the  humerus  the  upper  end  of  the  bone  is  the  usual 


Fig.  28. — Coronal  section  of  the  upper  end  of  the  tibia  showing  a  myeloma 
in  the  outer  tuberosity.     (From  a  woman  of  25  years.) 

site,  but  in  the  fernur  it  is  the  condyloid  end.  A  myeloma 
is  very  rare  in  the  patella  (Fig.  33). 

In  the  mandible  myelomas  affect  the  body  of  the  bone, 
but  in  the  maxilla  they  prefer  the  alveolar  border,  and  may 
sometimes  remain  in  the  early  stage  restricted  to  the 
premaxilla. 

Clinical  characters. — These  are,  as  a  rule,  sufficiently 
characteristic  to  ensure  accurate  diagnosis.     The  patients  are 


48 


CONNECTIVE. TISSUE    TUMOURS 


young,  rarely  above  25  years  of  age;  the  tumour  grows  quite 
slowly,  expands  tlie  bone,  and  thins  the  osseous  capsule  while 
expanding  it  until  the  bony  shell  is  so  thin  that  it  crepitates 
when  pressed  by  the  finger  (egg-shell  crackling).  Here  and 
there  the  myelomatous  tissue  perforates  the  capsule  and 
markedly  pulsates  synchronously  with  the  cardiac  systole. 
Myelomas  do  not  infect  lymph-glands,  nor  disseminate. 


Fig.  29.— Coronal  section  of  the  lower 
ends  of  the  tibia  and  fibula,  with 
the  astragalus;  a  myeloma  occupies 
the  lower  end  of  the  tibia.  (From 
a  woman  aged  23  years.) 


Fig.  30. — A  myeloma  of  the  upper  end 
of  the  radius  ;  from  a  man  of  28  years. 
(Museum,  St.  Thomas's  Sosjntal.) 


Treatment. — When  the  patient  comes  under  observation  be- 
fore the  tumour  has  perforated  its  capsule,  it  may  be  thoroughly 
extirpated  without  fear  of  recurrence.  The  manner  of 
thorough  extirpation  varies  with  the  situation  of  the  tumour. 

In  the  upper  limb,  the  lower  extremities  of  the  radius  and 
ulna  have  been  excised  for  myeloma,  leaving  an  extremely 
useful  hand.  It  is  an  important  fact  to  remember  that  the 
lower  third  of  the  ulna  may  be  excised  alone,  but  when 
the  radius  is  the  affected  bone  it  is  an  advantage  to  remove 


MYELOMAS 


49 


the  corresponding  section  of  the  uhia.  The  upper  third  of  the 
humerus,  the  inner  half  and  the  outer  half  of  the  clavicle  have 
been  resected  for  myeloma  with  excellent  results.     In  the  case 


RADIUS 


Fig.  31. — Myeloma  of  the  lower  eud  of  the  radius.     (Maseuij/,  St.  Thomases 
Hospital.) 

of  the  jaws  partial  excision  has  been  performed  for  myeloma 
with  good  consequences,  but  when  the  patient  allows  one  of 
these  tumours  in  the  maxilla  to  fungate  before  seeking  surgical 
aid,  the  marrow  tissue  will  so  invade  the  surrounding  soft 


Fig.  32. — Myeloma  of  the  acromial  end  of  the  clavicle  ;  from  a  woraan  of  26  years. 
{Museum,  Royal  College  of  Surgeons.) 

parts  that  complete  extirpation  is  a  chance  event  and  recur- 
rence is  probable. 

In   the   lower   limb    the   best   method    of   dealing    with 
myelomas  is  not  so  certain.     For  those  in  the  lower  end  of 
the  femur,  amputation  is  necessary.     This  method  has  also 
E 


50 


CONNECTIVE-TISSUE    TUMOURS 


been  employed  for  the  patella  by  Robert  Jones.  Excision 
has  been  successfully  employed  for  myelomas  in  the  head 
of  the  tibia  (Morton),  and  in  this  situation  a  milder 
method — enucleation,  first  suggested  and  practised  by 
Paget — has  given   excellent   results. 

A  close  study  of  myelomas  indicates  that  they  differ 
histologically,  pathologically,  and  clinically  from  sarcomas, 
with  which  they  have  hitherto  been  grouped. 

They  are  rare  tumours,  and  a  careful  perusal  of 
periodical  literature  and  hospital  reports  makes  me  think 
that  at  each  of  the  eleven  large  general  hospitals  in 
London  one  myeloma  a  year  is  above   the  average. 

The  subjoined  table  represents  the  good  results  which 
attend  the  surgical  treatment  of  this  genus  of  tumours. 


•■ 

Age  or  Patient 

Nature 

Keporter. 

AND 

BoKK  Affected. 

OF 

Operation. 

Result. 

Reference. 

Morris     .     . 

28.  Lower  end  of 

Resection  of  lower 

Free    from    recur- 

Trans. Clin.   Soc, 

radius 

ends  of  radius 

rence  16   years 

X.     138 ;    xiii. 

and  ulna 

later 

155  ;  xxii.  367. 

Lucas      .     . 

29.  Lower  end  of 

Resection  of  lo^^  er 

Free   from    recur- 

Trans. Clin.  Soc, 

ulna 

end  of  ulna 

rence  10   years 
later 

X.  135  ;  xxii. 
366. 

Bland-Sutton 

2C.  Acromial  end 

Resection  of  outer 

No   recurrence  17 

Trans.  Clin.  Soc, 

of  clavicle 

half  of  clavicle 

years  later 

xxiv.  12.  (See 
Fig.  82.) 

Glutton  .    . 

28.  Uppo.r  end  of 

Resection  of  upper 

Died  1 J  years  later 

Trans.  Clin.  Soc, 

radius 

fourth  of  radius 

of  albuminuria. 
No  recurrence 

xxvii.  86.  {See 
Fig.  30.) 

Glutton  .    . 

35.  Head  of 

Amputation 

No  recurrence    10 

Treves's  "System 

tibia 

years  later 

of  Surgery," 
i.  915. 

Bland-Sutton 

Preniaxilla 

Kxcision     of    the 
premaxilla 

No    recurrence    3 
years  later 

Unpublished. 

Bland-Sutton 

23.  Lower  end  of 

Am  putation 

No     recurrence    4 

Unpublished.  (See 

tibia 

through  middle 
of  the  leg 

years  later 

Fig.  29.) 

Jones  (Robert) 

20.  Patella 

Amputation 

No     recurrence    3 
years  later 

Trans.  Path.  Soc, 
xlvi.  143.  (See 
Fig.  33.) 

It  is  fair  to  assume  that  the  remarkable  case  in  which 
Mott  in  1828  excised  the  sternal  two-thirds  of  the  clavicle 
for  what  he  called,  in  the  terms  of  his  day,  "  an  osteo- 
sarcoma," in  a  lad  18  years  of  age,  was  in  all  probability 
a  myeloma.  The  boy  survived  the  operation  fifty  years 
(Porcher). 

One  of  the  difficulties  connected  with  the  treatment  of 
a  myeloma  is  the  doubtful  character  of  the  diagnosis  in 
some    instances.      A    myeloma    at    the    lower    end    of    the 


MYELOMAS 


51 


radius  is  rarely  missed,  but  in  other  long  bones  a  tumour 
of  this  kind  is  simulated  by  tuberculous  disease,  the 
common  species  of  sarcomas,  gumma,  and  (rarely)  echino- 
coccus  disease.  In  well-marked  examples  the  thinned  and 
expanded    bone    furnishes    the   classic    egg-shell   or   parch- 


rig.  33.— Myeloma  of  the  patella  ;  from  a  giil  of  20  years. 
{Museum,  Roijal  College  of  Surgeons) 

ment-like  crackling,  which  is  a  clinical  feature  of  great  value, 
and  was  especially  marked  in  the  myeloma  at  the  acromial 
end  of  the  clavicle  (Fig.    32). 

Butlin,  Henry  T.,  and  Colby,  F.  E.  A.,  "  On  Sarcoma  of  the  Bones  of  the  Thigh 
and  Leg." — St.  Bart's  Hos2).  Bejrts.,  1895,  xxxi.  31. 

Hinds,  "  Case  of  Myeloid  Sarcoma  of  the  Femur  treated  by  Scraping." — Brit. 
Med.  Joicrn.,  1898,  i.  555. 

Porcher,  F.  Peyre,  "  Post-mortem  Dissection  of  the  Kegion  of  the  Clavicle, 
this  bone  having  been  removed  for  Osteo-Sarcoma  by  Dr.  Valentine 
Mott,  of  New  York,  in  1828,  when  the  subject  was  in  his  19th  year, 
and  54  years  before  his  death." — Avier.  Journ.  Med.  Set.,  1883,  Ixxxv. 
146. 


CHAPTER  V 
SARCOMAS;    THEIR    HISTOLOGIC    CHARACTERS 

The  term  sarcoma  is  applied  to  any  connective-tissue  tumour 
which  exhibits  malignant  characters.  As  a  matter  of  fact, 
almost  any  kind  of  connective  tissue — fat,  bone,  cartilage,  and 
even  striated- muscle  tissue — may  occur  in  sarcomas,  but, 
as  a  rule,  the  greater  part  of  the  tumour  consists  of  imma- 
ture connective  tissue  in  which  cells  preponderate  over  the 
intracellular  tissue.  The  species  is  determined  according  to 
the  prevailing  type  of  cell :  thus  we  have  round-celled  and 
spindle-celled  sarcomas ;  some  contain  pigment,  and  are 
known  as  melano-sarcomas.  Of  each  there  are  one  or  more 
varieties,  which  have  received  qualif3dng  names,  such  as 
lympho-sarcoma,  m3^o-sarcoma,  chondro-sarcoma,  and  the  like. 

1.  Round -celled  sarcomas. — This  species  is  of  very 
simple  construction,  and  consists  of  round  cells  with  very 
little  intercellular  substance.  Each  cell  contains  a  large  round 
vesicular  nucleus,  and  a  small  proportion  of  protoplasm  ;  the 
nuclei  are  always  conspicuous  objects  in  stained  sections. 
Blood-vessels  are  abundant,  often  appearing  as  mere  channels 
between  the  cells.  Lymphatics  are  absent.  Round-celled 
sarcomas  grow  very  rapidly,  infiltrate  surrounding  tissues, 
recur  quickly  after  removal,  and  give  rise  to  secondary  dej)osits, 
especially  in  the  lungs. 

There  is  a  variety,  known  as  the  large  round-celled  sarcoma, 
in  which  the  cells  are  of  unequal  size  ;  some  of  them  contain 
two  or  more  nuclei ;  a  few  are  multinuclear  and  resemble 
myeloid  cells. 

The  round-celled  sarcoma  is  the  most  generalized  tumour 
that  affects  the  human  body ;  it  may  occur  in  any  tissue, 
osseous,  muscular,  nervous,  thymic,  ovarian,  or  testicular,  and 
even  in  the  delicate  sustentacular  framework  of  the  retina.  It 
attacks  the  body  at  all  periods  of  life,  from  the  foetus  in  utero 

52 


SARCOMAS  53 

and  the  child  just  born,  up  to  the  extreme  limits  of  age ;  and 
arises  in  vestigial  organs,  as  well  as  in  those  which  are 
in  the  full  exercise  of  their  functions,  such  as  the  kidney 
or  the  parotid  gland. 

2.  Lympho-sarcomas  consist  of  cells  identical  with  those 
of  the  round-celled  species,  but  the  cells  are  contained  in 
delicate  meshes:  the  tissue  resembles  that  of  lymph-glands 
(Fig.  34),  hence  the  origin  of  the  term  lympho-sarcoma.  These 
tumours  must  not  be  confounded  with  simple  (irritative)  en- 
largement of  lymph-glands,  nor  with  the  general  overgrowth  of 
lymphadenoid  tissue   associated   with   leukaemia   or   lymph- 


Fig.  34. — Microscopic  characters  of  a  lympho-sarcoma  from  the 
mediastiuum. 

adenoma  (Hodgkin's  disease).  The  lympho-sarcomas  exhibit 
a  very  characteristic  structure,  occur  as  a  rule  in  very  definite 
situations,  and  have  somewhat  special  clinical  features.  These 
tumours  occur  in  the  superior  mediastinum,  in  the  subpleural 
and  subperitoneal  connective  tissue,  at  the  base  of  the  tongue, 
in  the  larynx,  in  the  tonsil,  and  in  the  testis.  Fortunately, 
sarcomas  of  this  species  are  rare,  for  they  are  excessively 
malignant. 

3.  Spindle-celled  sarcomas. — The  cells  in  this  species 
vary  much  in  size,  but  they  all  agree  in  being  oat-shaped  or 
fusiform  (Figs.  35,  36).  The  cells  tend  to  run  in  bundles, 
which  take  different  directions,  so  that  in  sections  of  the 
tumour  seen  under  the  microscope  some  bundles  will  have 
the  cells  cut  in  the  direction  of  their  length,  and  others  at 


54 


CONNECTIVE -TISSUE    TUMOURS 


right   angles.     This  must  be  borne  in  mind,  or  an   incorrect 
opinion  will  be  formed  as  to  the  nature  of  the  tumour. 


Fig.  35. — Microscopic  characters  of  a  small  spindle-celled  sarcoma  from 
a  metacarpal  bone. 

In  some  sarcomas  the  cells  are  so  slender  and  contain  so 
little  protoplasm  that  they  appear  to  consist  of  merely  a  nucleus 


Fig.  36. — Section  of  a  spindle-celled  sarcoma  from  the  first  phalanx  of  the  thumb. 
{Sighly  magnified,') 

and  cell-processes.     In  others  the  cells  are  large,  fusiform,  and 
rich  in  protoplasm,  and  resemble  the  cells  of  young  unstriped 


SARCOMAS  55 

muscle.  Occasionally  these  spindle  cells  are  transversely 
striped  like  young  striated  muscle-fibre. 

Another  peculiarity  of  spindle-celled  sarcomas  is  the 
frequent  presence  of  tracts  of  immature  hyaline  cartilage ; 
indeed,  in  many  instances  this  tissue  constitutes  so  large  a 
proportion  of  the  tumours  that  they  are  described  as  chondro- 
mas ;  the  cartilage  is  sometimes  calcified,  and  even  ossified. 
It  may  seem  strange  to  associate  tumours  containing  striped 
cells  and  cartilage  with  sarcomas,  but  the  correctness  of  the 
classification  is  demonstrated  by  the  fact  that  such  tumours 
are  apt  to  recur  after  removal,  and  in  some  of  the  cases  in 
which  the  primary  and  recurrent  tumours  have  been  carefully 
examined  the  primary  tumour  has  contained  cartilage,  or 
muscle,  whilst  the  recurrent  mass  has  shown  no  evidence  of 
these  tissues,  but  has  conformed  to  the  structure  of  a  pure 
spindle-celled  or  a  round-celled  sarcoma.  In  order,  therefore, 
to  indicate  the  nature  of  such  composite  sarcomas,  they 
will  be  referred  to  as  myo-sarcomas  (rhabdo-rayomas)  and 
chondro-sarcomas.  Spindle-celled  sarcomas  often  contain 
round  and  even  multinuclear  cells. 

Myo  -  sarcomas. — It  is  a  remarkable  fact,  considering  the 
large  amount  of  striped-muscle  tissue  existing  in  the  body, 
that  tumours  composed  of  or  containing  this  tissue  do  not 
arise  in  connexion  with  the  voluntary  muscles,  but  make 
their  appearance  in  such  unexpected  situations  as  the  kidney, 
testis,  neck  of  the  uterus,  parotid  gland,  and  in  organs  and 
tissues  which,  under  normal  conditions,  do  not  contain  muscle- 
cells  of  the  striped  variety. 

Shattock  has  published  an  account  of  four  examples 
Avhich  grew  in  the  bladder  of  children.  The  tumour  in  each 
instance  assumed  the  polypoid  form  so  common  with  sarcomas 
growing  in  the  vagina  of  infants. 

M3^o-sarcomas  of  the  testis  have  been  mainly  observed  in 
children  (Hulke,  Neumann,  Ribbert). 

Prudden  has  found  cells  with  the  transverse  markings 
in  a  tumour  from  the  angle  of  the  mandible  of  a  boy  7 
years  of  age ;  other  examples  connected  with  the  periosteum 
have  been  reported  by  Zenker  and  Bayer,  who  found 
them  in  the  orbit.  Targett  found  one  on  the  scapula 
of  a  child  6  months  old  ;    and  Marchand  has  described  one 


56 


CONNECTIVE-TISSUE    TUMOURS 


which  grew   from    the   ischial   tuberosity  of  a   boy  4   years 
of  age. 

Pernice  has  recorded  in  detail  a  remarkable  example 
connected  with  the  neck  of  the  uterus.  The  tumour  con- 
tained a  large  number  of  transversely  striated  spindles 
(Figs.    37,    38).     The    tumour    was    removed,    but    quickly 


Fig.  37. — Racemose  sarcoma  of  the  neck  of  the  uterus,     {^fter  Fernice.) 

recurred ;  it  was  removed  a  second  time,  but  reappeared 
and  speedily  caused  death.  A  careful  examination  of  the 
recurrent  tumour  showed  it  to  consist  of  spindle  cells,  but 
no  striation  could  be  detected. 

Grape-like  (racemose)  sarcoma  of  the  neek  of  the  uterus. 
—  Pernice's  specimen,  to  which  reference  has  already 
been  made,  belongs  to  a  rare  variety  of  sarcoma,  of 
which  about  a  dozen  carefully  observed  examples  have  been 
described  since  Spiegelberg  drew  attention  to  this  disease 


8ABG0MAS 


57 


in  1879  (Whitridge  Williams).  Curtis  has  described  an 
example  which  occurred  in  an  infant  a  year  old,  and  has 
collected  the  literature.  In  some  of  the  specimens  the 
grape-like  bodies  are  covered  with  columnar  epithelium, 
the  bulk  of  the  grape  consisting  of  oedematous  spindle- 
and  round-celled  sarcomatous  tissue. 

In     an     example     which     I     had     an     opportunity     of 
examining,   the    grape-like   bodies   were    hollow,   and    lined 


Fig.  38. — Microscopic  characters  of  the  uterine  sarcoma  shown  in  Fig.  37, 
containing  muscle-cells.     (Pernice.) 

with  columnar  epithelium,  and  led  me  to  regard  them  as 
dilated  glands  in  the  cervical  endometrium  involved  in  a 
sarcoma. 

This  form  of  tumour  has  been  observed  exclusively  in 
girls  and  young  women:  it  is  very  malignant,  recurs 
locally,  invades  the  uterus  in  the  late  stages,  and  gives 
rise  to  metastases. 

Sarcomas  of  the  subperitoneal  tissue.  —  Very  large 
spindle-celled  sarcomas  are  occasionally  found  in  the 
belly    and    pelvis,   arising   in   the   subperitoneal   connective 


58  CONNECTIVE-TISSUE    TUMOURS 

tissue.  These  tumours  present  some  peculiar  features.  In 
tlae  first  place,  the}^  are  nearly  always  globular,  and  not 
infrequently  resemble  a  football  in  shape  and  in  size. 
They  have  been  observed  in  the  neighbourhood  of  the 
kidney,  and  in  some  instances  this  organ  occupies  a  recess 
in  the  tumour.  Retroperitoneal  sarcomas  of  this  kind 
often  have  the  adjective  perirenal  applied  to  them.  I 
have  removed  a  tumour  of  this  character  as  big  as  a  coco- 
nut from  between  the  layers  of  the  mesentery.  The  patient 
was  a  "woman  aged  25.  The  museum  of  McGill  College 
contains  a  large  globular  tumour  of  this  kind,  weighing 
eight  pounds,  which  was  removed  by  Shepherd  in  1897 
from  the  mesentery  of  a  man  aged  28  years  ;  eight  feet  of 
small  intestine  was  removed  at  the  same  time.  The  man 
was  alive  in  1900.  Many  of  the  tumours  reported  as 
"  m3^oma  of  the  broad  ligament  "  are  |)robably  large,  slowly 
growing  spindle-celled  tumours.  They  appear  to  be  the  least 
malignant  of  all  the  varieties  of  sarcomas,  and  are  extremely 
rare.  Many  of  the  reported  cases  weighed  upwards  of  thirty 
pounds. 

The  genus  sarcoma  is  certainly  very  heterogeneous  and 
unsatisfactory,  and  will  continue  so  until  the  cause  of 
malignant  connective-tissue  tumours  is  discovered.  The 
difficulty  in  regard  to  jfibromas,  myxomas,  and  myomas 
has  long  been  recognized ;  for  example,  fibromas,  or 
tumours  composed  of  fibrous  tissue,  were  regarded  as 
common,  but  careful  histologic  research  has  shown  them 
to  be  very  rare.  The  tumours  of  the  uterus  known 
as  myomas  and  ^fibro-myomas  were  formerly  regarded  as 
fibromas:  traces  of  this  belief  still  linger  in  the  term 
"  uterine  fibroids."  Many  tumours  now  called  spindle-celled 
sarcomas  were,  a  few  years  ago,  called  "  recurring  fibroids." 
The  difficulty  of  distinguishing  between  a  myoma,  a  slowly 
growing  spindle-celled  sarcoma,  and  a  fibroma  is  well 
known  to  skilled  histologists. 

Myxomas. — These  are  tumours  composed  of  tissue 
identical  with  the  jelly-like  substance  which  exists  in  the 
umbilical  cord.  Here  we  have  to  deal  with  a  difficulty, 
because  there  is  a  very  great  tendency  in  many  connec- 
tive-tissue tumours  to   degenerate  into  this   soft  gelatinous 


MYOMAS  59 

or    myxomatous    tissue    and    become    as    diffluent    as    the 
vitreous   body   in  the  eyeball. 

The  common  nasal  polypus  furnishes  an  excellent 
example  of  this  tissue ;  it  consists  of  cells  with  long, 
slender  processes  interlacing  with  those  of  adjacent  cells 
and  ramifying  in  a  structureless,  unstainable,  diffluent 
mass,  the  whole  being  bounded  by  a  thin  layer  of  mucous 
membrane  covered  with  columnar  ciliated  epithelium. 
Nasal  polypi  may  be  regarded  as  pendulous  processes  of 
(Edematous  mucous  membrane.  It  would  be  convenient  and 
justifiable  to  deprive  myxomas  of  even  the  rank  of  species 
among  tumours. 

The  heart  is  of  all  the  organs  of  the  body  the  least 
liable  to  tumours,  primary  or  secondary,  yet  the  few 
examples  of  primary  tumours  which  have  been  observed 
in  it  are  described  by  the  reporters  as  fibromas,  or 
myxomas,  or  fibro-myxomas.  The  chief  cases  have  been 
collected   and   the  clinical   signs  analysed  by  Pavlowsky. 

Myomas,  or  tumours  composed  of  unstriped-muscle 
fibre,  are  very  rare,  and  are  met  with  exclusively  in  organs 
containing  this  tissue,  e.g.  the  oesophagus,  stomach,  duo- 
denum, bladder,   and  uterus. 

Attention  has  already  been  directed  to  the  difficulty 
of  determining  between  the  fusiform  cells  of  sarcomas 
and  unstriped-muscle  fibre.  This  difficulty  is  increased 
by  the  fact  that  many  malignant  tumours  composed  of 
spindle  cells  (sarcomas)  contain  tracts  of  cells  which  pre- 
sent a  transverse  striation  such  as  is  seen  in  voluntary 
muscle  in  its  embryonic  stage ;  but  it  is  remarkable 
that  cells  with  the  transverse  striation  occur  in  situations 
where  voluntary  muscle  is  not  found  normally.  It  is  also 
a  fact  that  tumours  consisting  of  mature  striated  (volun- 
tary) muscle-fibre  have  not  been  observed.  Much  caution 
needs  to  be  exercised  before  deciding  that  a  tumour  is 
a  myoma;  formerly  many  of  the  spindle-celled  sarcomas 
of  the  choroid  were  regarded  as  myomas  arising  in  the 
ciliary  muscle.  It  is  also  extremely  probable  that  many 
of  the  tumours  described  as  myomas  from  the  oesophagus 
(Hilton  Fagge),  stomach,  duodenum,  bladder  (Parker, 
Terrier,  and  Hartmann),  and  vagina   were   sarcomas. 


60  CONNECTIVE -TISSUE    TUMOURS 

Dermatologists  are  familiar  with  small  tumours  ot  the 
skin,  which  are  occasionally  multiple,  and  consist  of 
smooth  muscle-fibres.  Such  myomas  may  arise  from  the 
arrectores  pili.  Marc  found  one  on  the  skin  of  the  occiput 
of  an  infant  which  had  a  diameter  of  3 '5  cm.,  and  I  re- 
moved one  from  the  scrotum  of  a  boy  a  few  months  old. 

In  two  instances  I  have  removed  tumours  from  the 
stomach  which  were  regarded  by  an  experienced  patho- 
logist (Foulerton)  as  leio-myomas.  In  one  instance  the 
tumour  was  as  big  as  an  almond ;  the  other,  as  large  as 
an  orange,  projected  from  the  serous  coat  at  the  great  cul- 
de-sac.  The  clinical  course  in  each  instance  justified  the 
microscopic  characters  as  to  benignity. 

The  common  situation  for  tumours  containing  unstriped 
muscle-fibres  is  the  uterus  (see  Fibroids). 

Bland- Sutton,  J.,  "  A  Tumour  of  the  Mesometrium  weighing  twenty-two 
Tponnds."— Trans.  Obstet.  Soc,  1900,  xli.  298. 

Clarke,  J.  Jackson,  "A  Large  Fibroma  of  the  Small  Omentum." — Trans.  Path. 

Soc,  1892,  xliii.  60. 
Curtis,  H.  J.,  "  Grape-like  Sarcoma  of  the  Cervix  Uteri." — Trans.  Oistet.  Soc, 

xlv.  320. 
Fagge,  C.  Hilton,  "Case  of  Myoma  of  the  CEsophagus." — Trans.  Path.  Soc, 

1895,  xxvi.  94. 
Hulke,  J.  W.,  and  Adams,  W.,  "  Tumour  of  the  Testicle  from  a  Young  Child." 

—Trans.  Path.  Soc,  1860,  xi.  162. 

Marc,  Serg.,  "Ein  Fall  von  Leiomyoma  subcutaneum  congenitum  nebst  einigen 
Notizen  zur  Statistik  der  Geschwiilste  bei  Kindern." — Virchow's  Arch.f. 
path.  Anat.,  cxxv.  543. 

Marchand,  Felix,  "  Ueber  eine  Geschwulst  aus  quergestreiften  Muskelfasern 
mit  ungewohnlichem  Gehalte  an  Glykogen,  nebst  Bemerkungen  iiber 
das  Glykogen  in  einigen  fotalen  Geweben." — Virchow's  Arch.  f.  path. 
Anat,  1885,  c.  42. 

von  Neiunann,  Prof.  E.,  "Ein  Fall  von  Myoma  striocellulare  am  Hoden." — 
Virchow's  Arch.  f.  path.  A^iat.,  1886,  ciii.  497. 

Parker,  R.  W.,  "  Case  of  Tumour  (Myoma)  of  the  Female  Bladder  removed  by 
the  Galvano-Cautery  through  a  Dilated  Urethra  combined  with  Supra- 
pubic Incision." — Trans.  Clin.  Soc,  1888,  xxi.  58. 

Pavlowsky,  "Beitrag  zum  Studium  der  Symptom atologie  der  Neubildungen 
des  Herzen-3.  Poly  pose  Neubildungen  des  einken  Vorhofs." — Berl.  hlin. 
Woch.,  1895,  xxxii.  393. 

Peraice,  Ludwig,  "Ueber  ein  traubiges  Myosarcoma  striocellulare  Uteri." 
— Virchow's  Arch.  f.  path.  A7iai,,  1888,  cxiii.  46. 

Prudden,  T.  M.,  "Ehabdo-Myoma  of  the  Parotid  Gland." — Ajuer.  Journ.  Med. 
Soi.,  1883,  Ixxxv.  438. 


REFERENCES  61 

Ribbert,  "  Beitrage   zur  Kenntniss  der   Rhabdomyome." — Yirchow's  Arch.  f. 
path.  Anat.,  1892,  cxxx.  249. 

Shattock,  S.  G.,  "  Rhabdo-Myoma  of  the  Urinary  Bladder."— Proc.  Roy.  Soc. 
Med.  Path.  Sec.,  1909,  p.  31. 

Shepherd,  F.  J.,  "  Successful  Removal  of  an  Enormous  Mesenteric  Tumour  and 
nearly  eight  feet  of  Intestine." — Brit.  Med.  Journ.,  1897,  ii.  966. 

Targett,  J.  H.,  "  Congenital  Myxo-Sarcoma  of  the  Neck  containing  Striped 
Muscle-Cells."— Trrms.  Path.  Soc,  1892,  xliii.  157. 

Terrier,  F.,  et  Hartmann,  H.,  "  Contribution  k  I'Etude  des  Myomes  de  la  Vessie." 
—Rev.  de  Chir.,  1895,  xv.  181. 

Williams,  Whitridge,   "  Contributions  to  the  Histology  and  Histogenesis  of 
Sarcoma  of  the  Uterus." — Avier.  Journ.  of  Ohstet.,  xxix.  721. 

Zenker,  Konrad,  "Zur   Lehre  von  der  Metastasenbildung   der   Sarcome." — 
Virchow's  Arch.  f.  path.  Anat.,  1890,  cxx.  68. 


CHAPTER  \l 

SARCOMAS  (Continued):     THEIR    GENERAL 
CHARACTERS 

Sarcomas  are  distinguished  from  the  preceding  genera  of 
tumours  in  rarely  possessing  capsules,  and  when  they  do  it  is 
generally  a  spurious  encapsulation  depending  on  environment, 
as  when  they  occur  in  the  kidney,  the  eyeball,  or  the  centre 
of  a  bone.  It  is  lack  of  a  capsule  which  permits  them  to  in- 
filtrate surrounding  tissues  and  favours  dissemination.  It  will 
be  convenient  to  devote  this  chapter  to  the  consideration  of 
the  way  in  which  sarcomas  display  their  malignancy. 

Blood-supply  of  sarcomas. — The  vascularity  of  sarcomas 
varies  greatly ;  in  all,  the  circulation  is  mainly  capillary.  In 
the  small  round-celled  species  the  vessels  are  so  numerous 
as  to  cause  distinct  pulsation  ;  in  the  slow-growing  spindle- 
celled  varieties — especially  those  undergoing  chondrification — 
the  vessels  are  not  numerous,  and  the  tumours  on  section  are 
yellowish  white.  It  has  already  been  pointed  out,  in  describing 
the  minute  structure  of  sarcomas,  that  the  walls  of  the  vessels 
are  very  thin,  and  are  often  so  attenuated  as  to  resemble 
channels  between  the  cells.  This  explains  the  frequency  of 
htemorrhage  within  the  soft  and  rapidly  growing  varieties. 
Repeated  extravasations  of  blood  will  sometimes  convert  these 
tumours  into  cysts  containing  blood  intermixed  with  sarcoma- 
tous cells.  Tumours  transformed  in  this  way  were  formerly 
described  as  malignant  blood- cysts. 

Although  the  vessels  in  a  sarcoma  are,  in  the  main,  capil- 
laries, nevertheless  the  -arteries  supplying  the  tumour  may  be 
very  large  and  numerous.  When  a  sarcoma  grows  from  the 
distal  end  of  the  femur  and  attains  a  large  size,  arteries  sup- 
plying it  from  neighbouring  muscular,  periosteal,  and  articular 
trunks  become  important  branches,  and  in  such  circumstances 
an  incision  into  the  tumour  will  be  attended  with  alarminsf 

62 


SARCOMAS 


63 


haemorrhage.  When  attempts  are  made  to  dissect  out  such  a 
tumour  from  the  Hmb  instead  of  adopting  more  radical 
measures,  such  as  amputation,  these  enlarged  vessels  must 
not  be  forgotten,  or  they  will  intrude  themselves  upon  the 
surgeon   in  a  very  unmistakable   manner.       Arteries  which 


Fig.  39.  — Section  of  lung,  with  nodules  of  sarcoma  secondary  to  a  chondi-if ying 
tumour  of  the  testis.     {Museum,  JRoi/al  College  of  Surgeons.) 

under  ordinary  conditions  are  almost  inappreciable  will,  when 
nourishing  a  sarcoma,  attain  the  dimensions  of  the  radial  or 
even  larger  trunks. 

Dissemination. — Sarcomas  are  liable  to  reproduce  them- 
selves in  distant  organs,  a  phenomenon  frequently  referred  to 
as  metastasis.  It  is  due  to  minute  particles  of  the  tumour 
growing  into   the   venules ;    these,   becoming   detached,    are 


64  CONNECTIVE-TISSUE    TUMOURS 

transported  by  tlie  current  of  blood  to  distant  organs,  where 
they  become  arrested  by  the  capillaries,  engraft  themselves, 
and  then  grow  into  independent  tumours.  This  dissemination 
takes  place  mainly  through  the  veins,  because,  as  already 
mentioned,  sarcomas  are  devoid  of  lymphatics.  The  most 
common  organ  in  which  to  find  secondary  sarcomas  is  the 
lung  (Fig.  39),  unless  the  primary  growth  is  situated  in  the 
territory  of  the  portal  circulation,  when  they  will  be  found  in 
the  liver.  In  very  malignant  examples,  especially  the  small 
round-celled  species,  secondary  deposits  may  form  in  any 
organ  of  the  body ;  they  are  always  identical  in  structure  with 
the  primary  tumour.  Secondary  deposits  of  sarcoma  in  the 
lungs  may  destroy  life  by  mechanically  obstructing  the  trachea 
and  bronchi.  I  have  known  a  nodule  to  slough  and  find  its 
way  into  the  trachea,  and  when  expelled  by  coughing  it  be- 
came impacted  between  the  vocal  cords  and  suffocated  the 
patient,  a  girl  of  19  years.  In  this  instance  the  primary 
tumour  was  a  periosteal  sarcoma  of  the  femur,  for  which  am- 
putation had  been  performed  several  months  before. 

Infiltrating  properties  of  sarcomas. — The  tendency  to 
extensive  infiltration  of  the  planes  of  connective  tissue  adja- 
cent to  the  tumour  is  not  peculiar  to  sarcomas,  for  it  is  an 
obvious  character  of  carcinoma.  This  property  of  sarcomas 
may  be  studied  in  a  marked  manner  in  the  case  of  mediastinal 
lympho-sarcomas.  These  tumours  grow  rapidly,  enveloping 
the  trachea  and  bronchi,  the  aorta  and  other  large  vessels, 
the  oesophagus,  and  large  nerve-trunks.  The  tumour  extends 
alonof  the  branches  of  the  bronchi,  and  invades  the  interlobu- 
lar  connective  tissue  at  the  roots  of  the  lungs.  When  the 
tumour  starts  in  the  superior  mediastinum  it  descends  along 
the  big  vessels  and  invests  the  pericardium.  It  may  even 
creep  along  the  sheaths  of  the  vessels  to  the  heart  and  infil- 
trate its  substance,  and  nodules  of  the  tumour  may  project 
into  the  cavity  of  the  auricles.  Processes  of  the  tumour  may 
find  their  way  along  the  sheaths  of  the  big  vessels  and  appear 
in  the  posterior  triangles  of  the  neck. 

The  relation  of  a  mediastinal  lympho-sarcoma  to  the 
adjacent  structures  is  interesting.  For  instance,  the  large 
arterial  trunks,  though  embedded  in  the  tumour,  are  not  as  a 
rule  damaged  by  it.     The  aorta  may  be  so  compressed  by  the 


Sarcomas  eh 

tumour  as  to  produce  a  murmur ;  the  thin-walled  veins  are 
early  compressed,  and  interference  with  the  venous  circula- 
tion is  a  marked  feature.  In  some  of  the  cases  infiltration  of 
the  walls  of  the  veins  takes  place,  and  processes  of  the  tumour 
project  into  their  channels. 

The  bronchi  are  very  liable  to  be  damaged  by  a  lympho- 
sarcoma, for  the  tumour  moulds  itself  round  these  tubes,  and 
by  pressure  causes  them  to  be  narrowed;  apart  from  this 
effect,  the  tissues  proper  of  the  tubes  become  eroded  and 
destroyed.  These  changes  not  only  induce  difficulty  in  re- 
spiration by  restricting  the  admission  of  air,  but  the  com- 
pression of  the  vessels  accompanying  the  bronchi  leads  to 
changes  in  the  nutrition  of  the  pulmonary  tissue,  which  end 
in  pneumonia,  gangrene,  and  death. 

The  important  nerves  traversing  the  mediastinum,  the 
vagus  and  phrenic  nerves  especially,  are  often  involved  in 
the  tumour,  but  their  sheaths  are  rarely  invaded  by  the 
cells ;  in  some  instances  the  left  recurrent  laryngeal  nerve  is 
compressed  sufficiently  to  produce  severe  laryngeal  spasms 
and  even  paralysis  of  the  muscles  supplied  by  it. 

The  oesophagus  becomes  squeezed  by  an  intrathoracic 
lympho-sarcoma,  but  dysphagia  is  not  so  prominent  a  symptom 
as  in  many  cases  of  intrathoracic  aneurysm.  The  oesophagus 
may  be  invaded  and  even  perforated  ;  when  this  happens, 
ulceration  and  sloughing  produce  a  cavity  in  the  tumour, 
and  may  even  broach  the  aorta  (Hale  White). 

It  is  a  somewhat  remarkable  feature  of  lympho-sarcomas 
that  they  extend  to  and  enclose  neighbouring  lymph-glands 
without  affecting  them  :  it  is  by  no  means  unusual  in  a  section 
of  a  large  mediastinal  sarcoma  to  find  bronchial  lymph-glands 
fully  charged  with  pigment  embedded  in  the  tumour  (Fig.  40). 
Some  writers  are  of  opinion  that  lympho-sarcomas  of  the 
superior  mediastinum  arise  in  the  thymus.  This,  of  course, 
is  possible,  but  it  is  very  difficult  of  proof. 

The  infiltrating  power  of  sarcomas  may  be  studied 
when  they  invade  the  sheath  of  a  muscle.  For  instance, 
when  a  retinal  sarcoma  protrudes  through  the  sclerotic 
and  invades  the  orbit  it  sometimes  makes  its  way  into  the 
sheaths  of  the  recti,  and  converts  them  into  masses 
resembling  yellow   wax.      On   microscopic  examination   the 

F 


ee  GONNEGTIVE-TISSJJE    TUM0VR8 

various  fasciculi  will  be  found  isolated  by  tbe  cells  of  the 
sarcoma.  Periosteal  sarcomas  often  invade  muscles,  and 
this  is  easily  comprehended  when  the  intimate  relations  of 
muscles  to  periosteum  are  remembered. 

Burrowing    tendencies     of    sarcomas.  —  All    tumours 
in   their    growth   tend   to   follow   the   lines  of  least   resist- 


Fig.  40. — Portion  of  a  mediastinal  lympho-sarcoma,  to  show  the  manner  in  which 
the  tumour  extends  along  the  bronchi  and  pulmonary  vessels. 

ance,  and  thus  enter  into  nooks  and  crannies  in  the  most 
unexpected  manner.  Every  surgeon  knows  how  a  sarcoma 
of  the  maxilla  will  send  processes  into  the  spheno- 
maxillary fossa  and  creep  through  the  foramen  rotundum, 
to  appear  in  the  cranial  cavity.  Sarcomas  springing  from 
the  heads  of  the  ribs  or  processes  of  the  vertebrae  have  been 
known  to  extend  through  intervertebral  foramina  and  com- 
press the  cord,  giving  rise  to  fatal  paraplegia  (Fig.  54,  p.  91). 


SARCOMAS  67 

It  is  also  remarkable  what  slender  barriers  will  serve  as 
checks  to  sarcomas.  For  example,  it  is  no  uncommon 
condition  for  one  of  these  tumours  springing  from  the 
periosteum  near  a  joint  to  extend  in  all  directions  and 
envelop  the  synovial  membrane,  yet  be  hindered  by  it  from 
invading  the  joint. 

!  Relation  of  sarcomas  to  veins.  —  It  has  long  been 
recognized  that  when  sarcomas  become  disseminated  the 
secondary  tumours  occur  in  situations  which  indicate  that 
the  distribution  has  been  effected  by  means  of  the  veins. 
Attention  has  been  drawn  already  to  the  tendency  which 
seems  inherent  in  most  species  of  sarcomas  to  burrow ; 
this  tendency  comes  out  in  a  striking  way  when  studied 
in  connexion  Avith  veins. 

Perhaps  the  simplest  form  occurs  in  the  eyeball.  When 
a  melanoma  arises  in  the  uveal  tract,  especially  when  the 
tumour  is  in  close  relation  with  the  choroid,  it  remains  for 
a  period  restricted  to  the  interior  of  the  globe,  until  it  pro- 
duces such  changes  in  the  intra-ocular  tension  that  the 
cornea  sloughs  and  the  growth  protrudes  externally.  In 
many  of  these  specimens,  if  the  sclerotic  be  carefully 
examined  in  the  situations  where  the  vense  vorticosse  pierce 
it,  small  nodules  of  the  tumour  will  be  detected  projecting 
through  these  openings,  having  made  their  way  out  by 
burrowing  in  the  sheaths,  and  in  some  cases  actually 
travelling  along  the  lumina  of  the  veins. 

The  relations  of  sarcomas  to  veins  come  out  strongly 
when  these  tumours  affect  bones.  In  some  examples  of 
periosteal  sarcomas  the  medulla  is  invaded  by  processes 
of  the  tumour  making  their  way  along  the  veins  traversing 
the  Haversian  canals.  The  converse  of  this  is  also  true, 
for  a  central  sarcoma  will  sometimes  implicate  the  perios- 
teum by  w^ay  of  the  Haversian  canals. 

It  is  well  established  that  most  examples  of  central 
sarcomas  occur  near  the  joint  ends  of  bones,  and  yet  it 
is  exceptional  to  find  the  joints  invaded.  When  joint  in- 
vasion happens,  it  occurs  late  in  the  course  of  the  disease, 
and  then,  in  most  cases,  the  tumour  creeps  in  through 
the  synovial  membrane.  This  comparative  immunity  of 
joints  is  usually  attributed  to  the  articular  cartilage  acting 


68  CONNECTIVE-TISSUE    TUMOURS 

as  neutral  tissue ;  but  it  appears  rather  to  be  due  to  the 
fact  that  the  cartilage,  unlike  the  compact  tissue  of  bone, 
is  not  traversed  by  a  multitude  of  narrow  venous  chan- 
nels. Extraordinary  examples  of  the  invasion  of  veins  by 
sarcomas   occur   in   the   abdomen.     In   cases    of    renal   sar- 


Inferior  vena  cava. 


Intravenous  process 
of  the  sarcoma. 


Glands   infected    by 
sarcoma. 


J A  sarcoma  springing 

i^  from  tlie  ilium. 


Fig.  41. — Periosteal  sarcoma  of  the  ilium  invading  the  inferior  vena  cava, 
{lliiseum,  St.  BarthoIo)neu-''s  Hospital.) 

comas,  processes  of  tumour  will  find  their  way  into  the 
renal  vein,  and  thus  enter  the  inferior  vena  cava.  Periosteal 
sarcomas  of  the  pelvic  surface  of  the  ilium  are  very 
liable  to  infiltrate  the  iliac  veins  and  extend  into  the  vena 
cava  (Fig.  41).  When  processes  from  a  sarcoma  project  into 
a  vein,  the  circulating  blood  is  apt  to  detach  large  frag- 
ments, and  these  become  dangerous  emboli. 

The  mere  presence  of  a  sarcomatous  outrunner  in  a  vein 


SARCOMAS  i  69 

does  not  necessarily  imply  dissemination  of  the  sarcoma, 
for  very  large  intravenous  processes  may  exist,  and  the 
lungs  be  free  from  any  gross  lesion  of  a  sarcomatous 
nature.  On  the  other  hand,  a  very  small  invasion  may 
lead  to  extensive  infection  of  the  lungs,  especially  if  the 
protruding  surface  of  the  tumour  be  eroded  by  the  blood- 
current. 

Dr.  Pitt  has  described  a  case  in  Avhich  a  man  with  sar- 
coma of  the  thyroid  gland  died  suddenly.  At  the  post- 
mortem examination  the  cavities  on  the  right  side  of  the 
heart  were  found  to  contain  fragments  of  growth  embedded 
in  clot ;  on  dissection  it  was  ascertained  that  the  sarcoma  had 
ulcerated  into  the  internal  jugular  vein. 

When  a  vein  is  invaded  by  a  sarcoma,  and  discharges 
of  emboli  frequently  occur,  they  easily  traverse,  when 
small,  the  right  auricle  and  ventricle,  but  are  too  large  to 
pass  through  the  pulmonary  capillaries;  hence  the  small 
vessels  in  the  lungs  act  as  filters,  and  these  arrested 
particles  act  as  grafts,  and  grow  into  secondary  nodules. 

Secondary  changes. — Sarcomas  are  very  prone  to  de- 
generative changes  ;  for  instance,  hsemorrhage  is  very  apt  to 
take  place  in  those  which  grow  quickly,  producing  spurious 
cysts.  The  tissues  of  the  tumour  are  prone  to  liquefy,  and 
myxomatous  changes  are  very  common.  Calcification  occurs 
in  those  which  grow  slowly,  especially  if  connected  with 
bone.  When  sarcomas  grow  rapidly  and  involve  the  skin, 
ulceration  may  occur  and  lead  to  profuse  and  oft-repeated 
haemorrhages,  which  not  only  exhaust  the  patient,  but  in 
many  cases  induce  death. 

Occasionally  considerable  portions  of  a  sarcoma  will 
necrose,  especially  in  very  large  tumours.  In  such  cases  a 
cavity  forms  in  the  sarcoma,  and  on  cutting  into  it  the  fluid 
escapes,  with  large  irregular  pieces  of  the  tumour,  which 
are  generally  of  a  greyish- white  colour.  When  necrosis 
occurs  extensively  in  a  large  sarcoma  it  will  sometimes  check 
the  course  of  the  tumour  in  a  very  marked  manner. 

Distribution. — As  connective  tissue  occurs  in  every 
organ  of  the  body,  so  sarcomas  are  ubiquitous,  but  they 
occur  in  some  situations  more  commonly  than  in  others. 
They   frequently   grow  from  subcutaneous  tissue  and  fascia, 


70  G0NNEGTIVE-TI88UE    TUMOURS 

periosteum,  the  testicle  and  ovary.  They  are  so  rare  as 
primary  tumours  of  the  liver,  spleen,  and  bowel  that  it  is 
not  possible  to  write  a  general  account  of  such  tumours, 
from  lack  of  material.  As  primary  tumours  of  voluntary 
muscles,  sarcomas  are  rare.  They  may  be  of  the  round- 
celled  or  the  spindle- celled  sj)ecies.  For  a  time,  at  least,  the 
tumour  is  limited  by  the  sheath  of  the  affected  muscle. 
At  first  the  tumour  appears  localized  to  a  particular  spot 
in  the  muscle,  but  it  gradually  extends  until  the  whole 
belly  of  the  muscle  is  involved  and  becomes  transformed 
into  an  indurated  mass.  On  section  the  muscle  appears  to 
be  replaced  by  hard,  tough,  pale-grey  material.  When 
sections  are  examined  under  the  microscope  the'  appear- 
ance is  very  striking,  for  each  fasciculus  is  isolated  from 
its  neighbour  by  collections  of  cells  characteristic  of  the 
sarcoma. 

As  in  sarcoma  of  other  organs,  haemorrhage  is  very 
liable  to  occur  in  the  substance  of  the  tumour,  leading  to 
the  formation  of  cavities  with  ragged  walls. 

Primary  sarcomas  have  been  recorded  in  the  follow- 
ing muscles :  rectus  abdominis,  peroneus  longus,  gracilis, 
tensor  vaginae  femoris,  adductor  brevis,  sartorius,  tibialis 
anticus,  and  the  triceps.  Four  cases  under  my  own  notice 
occurred  in  the  pectoralis  major,  the  extensor  carpi  radialis, 
the  adductor  longus,  and   the  vastus  externus. 

The  age-distribution  of  sarcoma  of  muscle  is  a  wide  one ; 
in  the  instances  enumerated  above,  the  youngest  patient 
was  18,  and  the  oldest  60  years.  The  disease  shows 
a  marked  preference  for  the  muscles  of  the  lower  limb. 

Extreme  care  is  necessary  to  avoid  mistaking  a  syphilitic  ■ 
gumma  in  a  muscle  for  a  sarcoma. 

It  is  a  curious  fact  that  sarcoma  of  nerves  should 
show  the  same  preference  for  the  lower  limbs  as  in  the 
case  of  muscles.  In  the  majority  of  instances  it  is  the 
great  sciatic,  or  its  branches,  the  popliteal,  posterior  tibial, 
peroneal,  or  the  plantar  nerves.  In  more  than  half  the 
cases  it  is  the  trunk  of  the  great  sciatic  which  is  attacked. 

Sarcoma  of  synovial  membrane. — A  primary  sarcoma  of 
a  synovial  membrane  is  a  rare  disease  ;  and  it  shows  the 
same  marked  preference   for   this   membrane  in  the   lower 


8ABG0MAS  71 

limb  as  is  the  case  with  muscles  and  nerves.  The  tumours 
may  be  of  the  round-  or  the  spindle-cell  species,  but  some 
contain  giant  cells  and  cartilage. 

The  disease  may  be  diffuse,  or  so  localized  as  to  be  a 
distinct  tumour,  and  it  rarely  takes  the  form  of  pedunculated 
bodies.  It  attacks  men  and  women  equally,  and  the  age  of 
the  patients  varies  from  20  to  35  years.  The  disease  is  of 
slow  progress,  and  causes  the  patients  very  little  incon- 
venience, as  it  does  not  interfere  with  the  movements  of  the 
joint.  The  diagnosis  is  a  matter  of  great  difficulty,  as  the 
disease  resembles  a  tuberculous  affection  of  the  joint  more 
strongly  than  anything  else.  In  Annandale's  patient  the 
disease  was  regarded  as  a  myeloma,  and  in  a  patient  under 
my  own  care  the  enlargement  of  the  joint  and  the  inter- 
ference with  its  mobility  were  attributed  to  loose  bodies,  and 
the  operation   was  undertaken  on  this  diagnosis. 

The  disease  lends  itself  to  three  kinds  of  operative 
treatment : — 

(a)  Enucleation,  when  the  disease  is  limited  to  a  por- 
tion of  the  synovial  membrane.  Turner  has  successfully 
practised  this  treatment  on  the  ankle-joint,  and  Howard 
Marsh  on  the  knee.  My  patient  was  free  from  recurrence 
five  years  after  the  operation  (Fig.  42). 

(6)  Resection  of  the  joint  when  the  sarcoma  is  diffuse. 

(c)  Amputation.  This  seems  to  be  the  best  guarantee 
against  recurrence,  and  is  a  method  of  treatment  more  par- 
ticularly resorted  to  when  the  sarcoma  is  diffuse. 

JuUiard  and  Descoeudres  have  reported  an  additional 
case,  collected  the  records,  and  carefully  summarized  the 
facts  relating  to  this  rare  disease. 

Primary  sarcoma  of  bursae. — It  is  well  known  that 
burste  are  prone  to  undergo  inflammatory  changes,  especially 
when  situated  in  exposed  situations,  such  as  those  which 
arise  in  relation  with  the  patella,  and  it  is  a  matter  of 
common  observation  that  a  prepatellar  bursa  when  chroni- 
cally irritated,  as  in  housemaids  and  carpet-layers,  will 
become  almost  solid :  specimens  illustrating  this  are  common 
in  pathological  museums.  There  are  a  number  of  care- 
fully observed  cases  which  show  that  a  bursa  may  become 
the  seat  of  sarcoma,  and  in  which  local  recurrence  followed 


72 


CONNECTIVE-TISSUE    TUMOURS 


extirpation  of  the  tumour.  Sarcomatous  bursse  have  been 
observed  in  connexion  with  the  patella,  the  semimem- 
branosus sac  at  the  knee-joint,  and  the  subdeltoid  bursa. 

The  chief  clinical  signs  on  which  a  diagnosis  may  be 
founded  would  appear  to  be  these  :  a  chronically  enlarged 
bursa  takes  on  active  growth,  and  becomes  firmer  in  con- 
sistence, and  this  is  accompanied  by  great  enlargement  of 
the  veins  in  the  skin  overlvino'   the  bursa. 


Fig.  i2. ^Pedunculated  bodies  removed  from  the  knee  ;  the  joint  contained 
thii'ty-six  such  bodies. 

It  must  be  remembered  that  prepatellar  bursse  in 
syphilitics  sometimes  rapidly  solidify. 

The  literature  of  sarcomas  arising  in  bursal  sacs  has 
been  collected  by  Adrian.  It  is  characterized  by  great 
poverty. 

Sarcomas  of  the  alimentary  canal.  —  Although  carci- 
noma is  the  prevailing  type  of  malignant  disease  which 
attacks  the  alimentary  canal  from  the  oesophagus  to  the 
anus,  cases  of  sarcoma  have  been  observed  and  reported  in 
sufficient  numbers  to  enable   their   leading  clinical  features 


SARCOMAS 


73 


to  be  summarized.  The  disease  arises  in  the  submucous 
tissue,  and  may  assume  the  form  of  a  j^olypus,  or  infil- 
trate the  wall  of  the  canal,  or  project  on  the  surface  of  the 
intestine  in  the  form  of  plaques.  All  species  of  sarcomas 
have  been  observed.  It  is  also  noteworthy  that  sarcomas 
are  more  prone  to  attack  those  regions  of  the  stomach  and 


Pedicle. 


Abscess  cavity. 


Tumour. 


Fig.  43.— Portion  of  jejunum  in  section  ;  a  pedunculated  tumour  had  invaginated  the 
bowel  and  produced  intestinal  obstruction.     (From  a  man  35  years  of  age.) 

intestines  which  are  in  a  measure  respected  by  carcinoma. 
Thus,  in  the  stomach,  sarcomas  prefer  the  body  of  the 
organ,  and  they  occur  with  greater  frequency  in  the  small 
than  in  the  large  intestine.  In  the  small  intestine  the 
liability  to  the  disease  increases  from  duodenum  to  ileum. 
Sarcomas  have  been  reported  in  the  vermiform  appendix. 
Secondary  deposits  appear  to  be  most  common  in  the  liver. 


74 


CONNECTIVE-  TI8S UE    TUMOURS 


One  of  the  most  important  clinical  features  Avhich 
distinguish  sarcoma  of  the  intestine,  large  or  small,  from 
carcinoma  is  its  occurrence  in  the  early  years  of  life; 
many  examples  have  been  observed  in  children.  The 
disease  runs  a  more  rapid  course,  causes  more  pain,  and 
forms  a  much  larger  tumour  than  is  the  rule  with  car- 
cinoma. As  a  sarcoma  often  tends  to  become  polypoid, 
the  occurrence   of  intussusception   is   a   frequent  complica- 


Fig.  44. — A,  Breast  in  section  showing  an  ossifying  sai'coma.     *  The  nipple.     B,  The 
osseous  element  of  the  tumour.     (Removed  from  a  woman  73  years  of  age.) 

tion  (Fig.  43).  The  results  of  operative  treatment  are 
unfavourable :  rapid  recurrence  is  the  rule.  Corner  and 
Fairbank  have  collected  and  analysed  the  records  of  this 
disease  in  an  admirable  paper  founded  on  a  case  under 
their  care. 

The  vagina  is  an  uncommon  situation  for  sarcomas, 
and  here  they  exhibit  unusual  characters  connected  with 
age-distribution — for   in   children   they  have   a  great   tend- 


SARCOMAS  75 

ency  to  become  polypoid,  or  they  form  flattened  masses 
in  tlie  submucous  layer.  Occasionally  the  tumours  may  be 
multiple.  Often  the  sarcoma  interferes  with  the  functions 
of  the  rectum  and  bladder.  The  literature  of  sarcoma 
of  the  vagina  in  infants  has  been  collected  by  Power  ; 
for  adults,  by  W.   Roger  Williams  and   Gow. 

Sarcoma  of  the  breast.— This  gland  is  liable  to  be  the 
seat  of  round-  and  spindle- celled  sarcomas.  They  are  rare 
tumours  and  grow  slowly  :  some  mammary  sarcomas  contain 
tracts  of  hyalin  cartilage  and  bone.  Examples  of  chondri- 
fying  tumours  have  been  described  by  Bowlby,  Battle,  Bruce- 
Clarke,  Morton,  and  Gordon  Watson.  The  only  specimen 
which  has  come  under  my  notice  occurred  in  a  multipara, 
aged  78  (Fig.  44).  The  tumour  in  this  case  was  so  hard 
that  it  had  to  be  cut  with  a  saw. 

A  perusal  of  the  reports  of  these  cases  shows  that  calci- 
fying and  chondrifying  tumours  of  the  breast  exhibit  the 
worst  features  of  sarcomas,  namely,  quick  recurrence. 

Treatment. — This  consists  in  the  wide  removal  of  the 
affected  part,  whenever  possible,  by  means  of  the  knife. 
The  method  of  effecting  this  varies  according  to  the  seat  of 
the  disease,  and  the  organ  affected.  In  the  ensuing  chapters 
dealing  with  the  distribution  of  these  tumours,  references  will 
be  made  to  the  principles  governing  the  surgical  treatment 
applicable  to  each  situation.  There  are  many  conditions, 
apart  from  the  size  of  the  tumour,  which  prevent  its 
complete  extirpation,  such  as  its  position  in  relation  to  vital 
organs,  and  generalization  (metastasis) :  when  sarcomas  do 
not  permit  of  radical  surgical  treatment  they  are  said  to 
be  inoperable.  Much  earnest  investigation  has  been  made 
with  the  hope  of  finding  some  means  by  which  patients 
with  inoperable  sarcoma  may  be  relieved,  especially  in  the 
domain  of  serumtherapy.     {See  Chap,  xxvii.) 

Adrian,  "  Ueber  die  von  Schleimbeuteln  ausgehenden  NeubilduDgens." — 
Bruns,  Beit.,  Bd.  xxxviii.  459. 

Bland- Sutton,  J.,  "  An  Ossifying  Sarcoma  of  the  Female  Breast."  This  paper 
contains  abstracts  of  five  similar  cases. — Arch,  of  Middx.  Hosjj.,  1910, 
xix.  98. 

Corner  (and  Fairbank),  "Sarcoma  of  the  Alimentary  Canal."— Traws. 
FatJi.  Soc,  Ivi.  20. 


76  CONNECTIVE-TISSUE    TUMOURS 

Gow,   St.  BartJs  Hasp.  Repts.,  1891,  xxvii.  97. 

Griffiths,  J.,  "Case  of  Villous  Sarcoma  of  the  Neck  and  Heart." — Trans. 
Path.  Soc,  1888,   xxxix.   311. 

JuUiard  et  Descoeudres,  "  Sarcoma  primitive  de  la  Synoviale  du  Genon." 
— Arch.   Internat.  de   Cliir.,   Gand,  1904,  p.  589. 

Lockwood,  "  A  Case  of  Sarcoma  of  the  Synovial  Membrane  of  the  Knee." 
— Trails.    Clin.   Soc,  London,   xxxv.   139. 

Marsh,  Howard,  "Primary  Sarcoma  of  the  Knee-Joint."  —  Lancet,  1898, 
ii.  1330. 

Pitt,  G.  Newton,  "  Sarcoma  of  Left  Lobe  of  Thyroid,  growing  round 
oesophagus,  and  invading  left  internal  jugular  vein  and  left  vagus. 
Ante-mortem  clot  on  right  side  of  heart,  containing  growth." — Trans. 
Path.  Soc.,  1887,  xxxviii.  398. 

Power,  D'Arcy,    St.  Part's  Hasp.  Repts.,  1895,  xxxi.  121, 

Salaman,  R.  N.,  "  Sarcoma  of  the  Stomach." — Trans.  Path.  Soc,  1904,  Iv.  296. 

Turner,  G.  R.,  "Primary  Sarcoma  of  the  Synovial  Membrane  of  the  Ankle- 
Joint." — Trans.  Clin.  Soc,  London,  xxxv.  137. 

Williams,  W.  R.,  "Vaginal  Tumours,"  1904. 


CHAPTER  VII 
SARCOMAS    OF   BONES 

These  tumours  arise  in  connexion  with  bones  in  two 
situations,  either  in  the  interior  of  a  bone,  or  in  the 
deeper  (osteogenetic)  layer  of  its  periosteum :  hence  they 
are  spoken  of  as   central  and  periosteal  sarcomas. 

1.  Central  sarcomas  may  arise  in  the  middle  of  the 
shaft,  but  more  frequently  they  originate  in  the  cancel- 
lous tissue  near  the  ends  of  the  long  bones.  Sarcomas 
arising  in  the  diaphysis  belong,  as  a  rule,  to  the  round- 
celled  species.  Those  which  grow  at  the  extremities  are 
generally  spindle-celled,  and  contain  a  variable  quantity 
of  myeloid  cells ;  cartilage  is  sometimes  present.  They 
occur  at  any  age,  but  are  most  frequent  between  10  and 
40,  and  are  more  common  in  the  long  bones  of  the 
lower  than  in  those  of  the  upper  limb. 

When  a  tumour  occuj)ies  the  centre  of  the  diaphysis, 
its  growth  causes  expansion  of  the  osseous  boundaries,  and 
produces  a  rounded  or  spindle-shaped  swelling,  and  the 
bone  may  become  so  thin  that  upon  some  slight  exer- 
tion it  breaks.  In  cases  where  the  tumour  affects  the 
extremity  of  the  bone  it  will,  in  young  subjects,  infiltrate 
the  epiphysis,  but  it  rarely  transgresses  the  articular 
cartilage. 

Central  sarcomas  rarely  affect  the  adjacent  lymph- 
glands.  In  exceptional  cases,  especially  with  small  round- 
celled  sarcomas,  the  cells  will  make  their  way  along  the 
Haversian  canals  and  form  a  tumour  beneath  the  perios- 
teum. Central  sarcomas  lead  to  enlargement  of  the  sur- 
rounding bone;  hence  when  the  soft  tissues  are  removed 
by  maceration  a  large  bulb-like  osseous  mass  is  left.  These 
specimens  are  common  in  pathological  museums.  In  some 
cases  this  osseous  capsule  is  so  thin  that  the  tissue  of 
'  the    tumour    makes    its    way    through,    and    as   it    is  very 

77 


78  CONNEGTIVE- TISSUE    TUMOURS 

vascular   a    strong  rhythmical   pulsation  (accompanied  by  a 
bruit)  is  perceptible  over  the  protruding  portion. 

2.  Periosteal  sarcomas. — These  may  be  round-celled  or 
spindle-celled,  and  are  liable  to  the  various  metamorphoses 
and  degenerations  afi'ecting  sarcomas  generalh",  but  are 
more  liable  to  calcification  and  ossification  than  central 
tumours.  They  occur  earlier  in  life  than  those  of  the  pre- 
ceding class,  and  are  frequently  associated  with  antecedent 
injury.     They  do  not,  as  a  rule,  invade  joints. 

When  growing  from  the  periosteum  near  the  middle  of 
the  shaft,  a  sarcoma  may  be  restricted  to  a  portion  of  its 
circumference,  or  entirely  surround  it,  producing  a  fusiform 
swelling.  In  such  specimens  the  shaft  of  the  bone  traverses 
•  the  tumour,  and  beyond  a  slight  amount  of  erosion,  may 
be  unaffected  by  it.  In  such  a  case,  however,  the  medulla 
is  sometimes  infected  by  the  cells  making  their  way  along 
the  Haversian  canals.  Periosteal,  like  central,  sarcomas  have 
a  greater  predilection  for  the  joint  ends  of  the  bone  than 
for  the  central  portion  of  its  shaft. 

In  size  periosteal  sarcomas  vary  greatly  ;  in  exceptional 
cases  they  have  been  known  to  exceed  a  metre  (40  inches) 
in  circumference.  Many  become  more  or  less  ossified,  the 
osseous  matter  taking  the  form  of  delicate  spicules  arranged 
at  right  angles  to  the  shaft  of  the  bone;  sometimes  it 
forms  an  irregular  bony  mesh,  the  spaces  being  filled  with 
sarcomatous  tissue.  In  some  specimens  the  bone  is  greatly 
thickened  in  the  parts  related  to  the  tumour.  The  exten- 
sive ossification  associated  with  sarcoma  of  the  periosteum 
is  not  a  matter  for  surprise  when  we  remember  the  bone- 
forming  function  of  this  tissue.  The  crystal-like  sjDicules 
so  frequently  found  probably  represent  ossification  of  the 
fibrous  trabeculse  which  connect  the  periosteum  with  the 
compact  tissue  of  the  shaft ;  as  the  periosteum  is  raised 
from  the  bone  by  the  growing  tumour,  these  trabeculse 
elongate  and  subsequently  ossify. 

The  femur. — This  bone  is  very  liable  to  sarcomas, 
especially  the  periosteal  variety ;  they  are  most  frequently 
associated  with  its  lower  third,  and  invariably  run  a  rapidly 
fatal  course,  the  duration  of  life  rarely  exceeding  eighteen 
months;    often   it   is   very  much  less.     Usually  they   occur 


8ABG0MA8    OF   BONES  79 

between  the  fifteenth  and  fortieth  years.  A  sarcoma 
situated  at  the  lower  end  of  the  femur  often  simulates 
disease  of  the  knee  very  closely,  and  gives  great  difficulty 
in  diagnosis ;  also  a  sarcoma  of  the  femur  may  invade 
the    knee-joint    and    resemble    a    primary   sarcoma   of    the 


Fig.  45.  —An  ossifying  spindle -celled  sarcoma  of  the  femur :  in  transverse  section. 

synovial  membrane  of  that  joint.  The  rapidity  with  which 
a  periosteal  sarcoma  of  the  femur  will  destroy  the  patient, 
especially  when  it  occurs  in  early  life,  is  illustrated  in 
the  following  case : — A  man  24  years  of  age  felt  pain  in 
his  knee ;  a  month  later  it  was  found  that  a  sarcoma 
occupied  the  lower  end  of  his  femur.  Two  months  afterwards 
he  came  under  my  care,  and  the  leg  was  promptly 
amputated.     The  tun^our,  a  periosteal  sarcoma,  had  circum- 


80 


OONNEGTIVE-TISSTIE    TUMOURS 


scribed  the  lower  portion  of  the  femur  (Fig.  45).  A  few 
days  after  the  operation,  difficulty  of  breathing  began  to 
declare  itself,  and  a  month  after  the  operation  the  man 
died,   slowly   suffocated.     At    the  post-mortem   examination 


Fig.  46.  — Skeleton  of  an  ossifying  periosteal  sarcoma  of  the  femur. 

secondary  deposits  were  found  in  the  liver,  pancreas,  and 
ileum.  The  lungs  were  thickly  occupied  with  secondary 
deposits ;  and  a  large  conglomerate  mass  as  big  as  the  fist 
compressed  the  trachea  and  adjacent  segments  of  the 
bronchi.     All  the  secondary  deposits  were  hard  and  grated 


SARCOMAS  OP  BOKPS 


81 


under    the    knife,   and    some    of    tliem  seemed    to  be   con- 
tained in  an  imperfectly  formed  osseous  capsule,  or  shell. 
In     its     general     characters — the     disposition     of     the 


Epiphysis. 
Epipliysial  line. 


Cancellous    tissue,     with 
red  marrow. 


Medullary  canal. 


Periosteum. 


Sarcoma. 


BtROEAU 


Fig.  47. — Coronal  section  of  the  tibia  of  a  girl  with  a  periosteal  sarcoma.     She  was 
alive  and  well  five  years  after  the  amputation. 

secondary  deposits — and   in  the  mode  by  which  it  destroyed 
this    man    the     sarcoma    displayed    thoroughly    the    usual 
features    of   an   ossifying  periosteal   sarcoma   of    the   femur. 
G 


82 


G0NNWTIVB-TI88UE    TUM0UB8 


This   man  had   no   notion   that   anything   was   wrong   with 
his  thigh  until  October,  and  by  the  middle  of  the  following 


/3i-T7£/-y«|\TH-[c 


Fig.  48.  —Tibia  and  fibula.     The  tibia  is  greatly  expanded  throughout  its  length  by  a 
central  sarcoma.   From  a  man  24  years  of  age.    {Museum,  Royal  College  of  Surgeons.) 


8JBC0MAS   OF  BONES  83 

February  he  was    suffocated   by  large  secondary  nodules  of 
sarcoma  compressing  the  bronchi. 

The  tibia. — -Sarcomas   are   fairly   common   in  this  bone ; 
they   prefer   the  upper  to  the  lower  end,  and   they   do   not 


Accessary      nodule     of 
sarcoma. 


Interosseous  membrane. 


—    Sarcoma. 


Flexor  longus  liallucis. 


Peroneus  longus. 

—  Detached  portion  of  the 
flexor  longus  liallucis 


Fig.  49. —Spindle-celled  sarcoma  of  the  fibula.     {Museum,  Middlesex  Hospital.) 

run  such  a  rapid  course  as  in  the  femur.  For  instance,  I 
have  had  the  opportunity  of  following  nine  cases  of  sarcoma 
of  the  fenmr  throughout  their  whole  clinical  course.  All 
the  patients  died  within  a  year  of  operation  from  dissemi- 
nation of  the  tumour  or  from  local  recurrence.  In  the 
case  of  the  tibia  I  have  known  several  patients,  who  have 


84 


CONNECTIVE-TISSUE    TUMOURS 


survived   amputation   of  the   leg  for  periosteal  sarcoma,  to 
be  alive  and  in  good  health  five  years  later  (Fig.  47). 

A  very  large  proportion  of  central  tumours  of  the  tibia, 
formerly  classed  as  sarcomas,  now  rank  with  myelomas, 
and  I  am  inclined  to  think  that  spindle-celled  and  round- 


Fig.  50. — Periosteal  sarcoma  of  the  upper  portion  of  the  fibula.     The 
side  figure  shows  the  bone  in  section. 

celled  central  sarcomas  of  the  tibia  are  rare  tumours.  The 
extraordinary  manner  in  which  a  central  sarcoma  of  the 
tibia  will  expand  the  bone  is  well  shown  in  Fig.  48.  The 
details  of  this  remarkable  case  have  been  reported  by  Eve. 
The  fibula.  —  This  bone  is  not  often  attacked ;  the 
upper  end  is  the  favourite  situation,  but  periosteal  sarco- 
mas may  spring  from  any  part  of  its  shaft.    (Figs.  49,  50,  51.) 


SARCOMAS   OF  BONES 


85 


Sarcomas  of  this  bone  are  interesting  because  its 
upper  half  is  vestigial,  and  its  persistence  is  probably 
mainly  due  to  the  fact  that  it  affords  attachment  to  the 
muscles  of  the  leg.  The  lower 
one-third  has  undergone  ex- 
cessive development  to  meet  the 
demands  of  the  ankle-joint 
for  greater  security  necessitated 
by  the  upright  position  in  man. 
These  facts  induced  me  some 
years  ago  to  depart  from  the 
usual  rule  in  treating  periosteal 
sarcoma  of  the  fibula.  We  know 
that  when  these  tumours  at- 
tack the  bones  of  the  leg  they 
do  not  run  a  very  rapid  course, 
so  in  a  favourable  case  which 
came  under  my  care  in  1895  I 
resected  the  upper  half  of  the 
fibula.  The  patient  recovered 
with  a  very  useful  limb,  and 
was  able  to  walk  about.  Ke- 
currence  took  place  in  the  scar 
eighteen  months  later ;  this  was 
removed.  Six  months  after- 
wards a  more  extensive  recur- 
rence rendered  amputation  a 
necessity.  The  patient  died,  two 
3^ears  and  six  months  after  the 
original  operation,  with  signs 
indicating  dissemination  in  the 
lungs. 

A  careful  examination  of  the 
literature  relating  to  sarcoma 
of  bone  makes  me  think 
that  these  tumours  are  rare 
in  the  fibula,  and  certainly  they  do  not  run  a  very  rapid 
course. 

The    humerus. — Periosteal    sarcomas    of    this   bone   are 
very  dangerous  to  life ;  they  occur  at  all  ages,  and  generally 


Fig.  51. — Fibula  showiDg  the  change 
IDrocluced.  by  a  central  sarcoma 
growing  in  its  upper  end. 


86  GONNEGTIVE-TISSUE    TUMOURS 

involve  the  whole  shaft  o±  the  bone,  and  form  large,  soft, 
rapidly  growing,  spindle-shaped  masses. 

Sarcomas  situated  at  the  upper  end  of  the  humerus 
have  been  very  freely  operated  upon  since  1887  by  the 
interscapulo-thoracic  method  of  amputation.  The  immediate 
results  are  good,  but  the  remote  consequences  are  dis- 
couraging. 

The  radius  and  ulna.  —  Sarcomas  of  these  bones, 
whether  central  or  periosteal,  are  so  rare  that  it  is 
impossible  to  collect  a  sufficient  number  of  cases  to  make 
deductions  of  any  value.  The  few  available  records  are 
sufficient  to  show  that  amputation  has  been  followed  by 
good  consequences,  immediate  and  remote.  Some  of  these 
tumours,  however,  may  have  been  myelomas. 

Clavicle.  —  Periosteal  sarcomas  of  this  bone  are  rare, 
and  in  nearly  all  the  recorded  cases  have  originated  near 
the  middle  of  the  bone.  A  fair  number  of  cases  have  been 
reported  in  which  the  bone  and  tumour  have  been  suc- 
cessfully excised.  Examples  reported  to  be  central  sarcomas 
arose  mainly  in  the  sternal  end,  but  these  were  in  all  prob- 
abiHty  myelomas.  Partial  or  complete  extirpation  of  the 
clavicle  does  not  impair  the  utility  of  the  limb. 

Scapula. — It  is  easy  to  collect  a  score  or  more  of  records 
relating  to  sarcomas  of  the  scapula.  They  arise  mainly 
from  the  periosteum  of  the  dorsal  and  ventral  surface  of 
this  bone,  and  often  assume  formidable  proportions.  It  is 
rare  for  sarcomas  to  arise  in  connexion  with  the  pro- 
cesses of  the  scapula,  but  a  central  sarcoma  of  the  coracoid 
process  has  been  observed. 

Scapular  sarcomas  are  usually  of  the  spindle-celled 
species,  and  many  of  them  chondrify  and  ossify,  often  very 
extensively  (Fig.  52). 

Since  1887,  when  Berger  introduced  the  operation 
known  as  interscapulo-thoracic  amputation^  many  surgeons 
have  removed  the  scapula  and  upper  limb  in  cases  of 
scapular  sarcoma.  The  immediate  results  of  this  formid- 
able operation  are  very  gratifying,  and  though  in  a  large 
proportion  of  the  patients  there  is  a  quick  recurrence, 
nevertheless  life  is  more  often  prolonged  than  in  amputation 
for    sarcomas    of  many    of    the    long   bones.      Occasionally, 


SARCOMAS   OF  BONES 


87 


when  a  sarcoma  is  confined  to  a  limited  area  of  the  scapula, 
it  is  possible  to  excise  the  body  of  the  bone,  leaving  the 
head  in  its  normal  relation  to  the  shoulder-joint :  some 
patients  have  recovered  from  this  operation  with  a  useful 
upper  limb. 


Fig.  52. — Skeleton  of  a  periosteal  sarcoma  of  the  scapula. 
{lluseum,  St.  Thomas's  HQspital.) 

Innominate  bone. — Sarcomas  occasionally  arise  in  con- 
nexion with  this  bone ;  they  may  be  periosteal  or  central, 
and  may  occur  in  any  part  of  it.  On  the  whole,  the  iliuni 
is  the  segment  most  commonly  affected,  and  the  tumours 
attain  a  great  size.  Stimulated  by  the  success  of  the 
interscapulo-thoracic  amputation  for  sarcoma  of  the  scapula 


88  CONNECTIVE-TISSUE    TUMOURS 

attempts  have  been  made  to  remove  tlie  innominate  bone,  or 
the  greater  part  of  it,  with  the  lower  limb,  as  a  radical  means 
of  dealing  with  sarcoma  of  the  ilium.  This  operation  has 
been  termed  tbe  interilio-abdominal  amputation  (Jaboulay, 
1894).  Keen  and  Da  Costa  have  collected  fifteen  cases  and 
added  one  under  their  own  care.  The  results  are  not 
encouraging. 

Sternum. — This  bone  is  sometimes  the  seat  of  primary 
sarcoma,  and  a  few  surgeons  have  excised  portions  of 
the  bone  with  the  hope  of  eradicating  the  disease.  The 
results,  immediate  and  remote,  are  not  calculated  to  bring 
the  operation  into  favour.  Keen  has  reported  a  very  suc- 
cessful example  and  collected  the  best-known  cases. 

Ribs. — Sarcomas  attack  the  ribs,  and  when  they  grow 
from  the  heads  or  necks  of  these  bones  are  apt  to  send 
processes  through  the  intervertebral  foramina,  which,  extend- 
ing into  the  spinal  canal,  compress  the  cord.      (Fig.  54.) 

A  number  of  instances  have  been  described  in  which 
surgeons  have  removed  costal  sarcomas,  in  some  cases 
without  opening  the  pleura ;  but  the  results  are  not 
encouraging,  and  in  the  cases  where  the  pleura  was 
opened  in  the  course  of  the  operation  the  effects  upon 
respiration  and  circulation  were  very  grave.  Webber,  in 
removing  a  spindle-celled  sarcoma  of  the  sixth  rib  from  a 
man  46  years  of  age,  opened  the  left  pleura  and  the  peri- 
cardium.    The  jDatient  recovered. 

Bones  of  the  hand  and  foot. — Sarcomas  of  the  meta- 
carpal and  metatarsal  bones,  or  the  phalanges,  are  very  ex- 
ceptional. Large,  rapidly  growing  sarcomas  arise  from  the 
tarsus,  but  it  is  unusual  to  find  a  central  tumour  in  these 
cubical  bones,  though  the}^  have  been  reported  in  the  cal- 
caneum  (Barthauer). 

Sufiicient  facts  are  not  available  to  enable  anything 
like  a  satisfactory  account  to  be  furnished  of  the  clinical 
course  of  sarcomas  of  the  hands  and  feet;  this  is  due  to 
their  rarity. 

Patella. — A  sarcoma  of  this  bone  is  a  great  rarity,  but 
a  careful  report  of  a  case  has  been  published  by  Parker. 

The  skull. — The  large  bones  of  the  cranial  vault  — 
parietal,    squamo-occipital,    and    the   tabular   portion    of  the 


SARCOMAS  OF  BONES  89 

frontal  —  are  liable  to  be  attacked  by  periosteal  sarcomas  ; 
they  grow  rapidly,  and  form  large  tumours  which  cannot 
often  be  submitted  to  surgery.  Pathological  museums  of 
any  pretensions  usually  contain  one  or  more  crania  exhibit- 
ing the  peculiar  formation  of  spiculated  new  bone  charac- 
teristic of  a  periosteal   sarcoma. 

The  mesethmoid  is  an  unusual  situation  for  a  sar- 
coma, but  Moore  has  described  an  example  which  is 
interesting  from  the  very  extraordinary  effects  it  pro- 
duced, for  as  the  tumour  increased  in  size  it  compressed 
the  walls  of  the  antrum  and  flattened  out  the  body  of 
each  maxilla  until  these  bones  formed  a  thin  expanded  shell 
to  the  tumour,  but  the  bones  were  not  eroded  or  invaded 
by  it.  The  sarcoma  also  greatly  widened  the  space  between 
the  orbits  and  caused  great  deformity  of  the  face,  but 
did  not  invade  the  skull.  There  was  no  pain.  Moore 
attempted  the  formidable  task  of  removing  this  tumour, 
but  the  patient  died  during  its  progress.  The  parts  are 
preserved  in  the  museum  of  the   Middlesex  Hospital. 

Sarcomas  arising  in  the  muco-periosteum  of  the  roof 
of  the  pharynx  constitute  an  important  clinical  group 
under  the  name  of  naso-pharyngeal  tumours.  They 
are  commonly  met  with  in  patients  between  the 
ages  of  15  and  20,  and  in  many  cases  arise  from  the 
muco-periosteum  of  the  under-surface  of  the  body  of 
the  sphenoid,  and  in  some  instances  from  that  lining 
the  sphenoidal  sinuses.  Such  tumours  sometimes  extend 
into  and  plug  one  or  both  nasal  fossse,  processes  of  the 
tumour  appearing  at  the  nostril ;  or  they  may  extend 
downwards  into  the  pharynx  and  impede  deglutition. 
Sometimes  the  base  of  the  skull  is  perforated  by  the 
tumour,  and  the  patient  dies  of  meningitis.  Naso-pharyn- 
geal sarcomas  often  cause  agonizing  pain  and  intense 
frontal  headache.  Whilst  the  pain  wears  out  the  patient, 
his  strength  is  further  exhausted  by  frequently  recurring 
and  often  profuse  epistaxis.  Exceptionally,  a  piece  of  the 
tumour  will  slough  and  become  impacted  in  the  larynx ; 
suffocation  has  followed  this  accident. 

Sarcomas   of  the  jaws. — Although  it   is   customary  to 
speak   of  sarcomas  which   are   connected  with    the  maxilla 


90 


CONNECTIVE- TISSUE    TUMOURS 


and  mandible  clinically  as  tumours  of  the  jaws,  it  would 
be  erroneous  to  describe  them  indiscriminately  as  tumours 
of  bone.  In  each  jaw  there  are,  in  addition  to  the  bone  and 
periosteum,  two  structures  to  consider — mucous  membrane 
and  teeth.  In  the  case  of  the  maxilla,  the  antrum  requires  to 
be  considered,  with  its  gland-containing  muco-periosteum. 

Periosteal  sarcomas    of  the    jaws    are    rare    before    the 
fifteenth   year,   but    they   may   occur   at   any   age,   even   in 


Fig.  53. — Large  recurrent  sarcoma  of  the  mandible. 

infants  a  few  months  old.  They  belong  to  the  round-  and 
spindle-celled  species,  and  grow  very  rapidly  (Fig.  53). 
These  tumours  are  less  frequent  on  the  mandible  than  the 
maxilla ;  they  grow  from  any  part  of  it  Those  which 
spring  from  the  outer  surface  of  the  ramus  are  apt  to  be 
mistaken  for  parotid  tumours. 

Periosteal  sarcomas  originate  in  any  part  of  the 
maxilla,  but  they  rarely  arise  from  its  facial  surface,  and, 
though  fairly  frequent  on  the  gums,  are  very  rare  in  con- 
nexion with  the  mucous  membrane  of  the  palatine  process. 
The  muco-periosteum  of  the  antrum  is  a  common  situa- 
tion for  these  tumours,  and  as  they  grow  they  cause  thin- 


SARCOMAS  OF  BONES 


91 


ning  and  expansion  of  the  walls  of  tliis  chamber.  This 
enlargement  of  the  body  of  the  maxilla  causes  it  to 
encroach  on  the  nasal  fossa  and  obstruct  respiration ;  often 
the  tumour  pushes  up  the  orbital  plate  and  displaces  the 
eyeball  (proptosis),  and  in  a  certain  proportion  of  cases 
the  alveolar  border  is  depressed.  The  nasal  duct  is  fre- 
quently implicated,  and  when  it  is  completely  obstructed 
epiphora  is  the  consequence.     Clinically,  a  sarcoma  originat- 


Fig.  54. — Chondrifyiug    sarcoma    of   the    vertebrte   and   ribs.     A   portion    of    the 
tumour  crept  into  the  spinal  canal  and  produced  fatal  paraplegia.     {Museum, 

St.  Bartholomew'' s  Hospital.) 

ing  within  the  antrum  expands  its  walls,  and  by  degrees 
processes  of  the  tumour  make  their  way  through  and 
implicate  the  skin  of  the  cheek,  or,  projecting  into  the 
nasal  fossa,  ulcerate  and  give  rise  to  frequently  recurring 
hiEmorrhage.  When  the  tumour  perforates  the  posterior 
wall  of  the  antrum,  it  will  enter  the  zygomatic  and 
spheno- maxillary  fossfe,  and  creep  thence  into  the  temporal 
fossa,  or  make  its  way  through  the  spheno-maxillary 
fissure  and  ramify  in  the  orbit,  or  steal  through  the 
sphenoidal  fissure  or  foramen  rotundum  into  the  middle 
fossa  of  the  cranium. 


92  CONNECTIVE-TISSUE    TUMOURS 

Sarcomas  of  the  palate. — The  mucous  membrane  of 
the  hard  and  soft  palate  is  hable  to  mahgnant  tumours  be- 
longing to  the  sarcomas  and  squamous-celled  carcinomas. 
It  is  also  liable  to  a  peculiar  tumour  which  is  somewhat 
rare,  named  "  adenoma  of  the  palate."  These  tumours  are 
usually  ovoid  in  shape,  and  vary  in  size  from  a  cob-nut 
to  a  hen's  egg  ;  they  occur  more  frequently  in  the  soft  than 
in  the  hard  palate,  and  are  invariably  encapsuled.  These 
"  palatine  adenomas "  are  complex  in  structure.  Some 
possess  glandular  tissue  with  ill-formed  ducts  and  acini 
which  in  their  structure  mimic  cancer,  whilst  the  stroma 
in  which  they  are  embedded  imitates  sarcomatous  tissue. 
They  occur  most  strongly  between  the  thirtieth  and  fiftieth 
years,  but  they  have  been  met  with  at  puberty.  They 
are  innocent  tumours.  They  have  been  carefully  studied 
by  Stephen  Paget  and  Hutchinson,  jun.  Many  tumours 
described  as  sarcomas  of  the  jaws  are  endotheliomas. 

Vertebrae. — Primary  sarcomas  of  the  vertebral  column 
are  rare  tumours.  They  tend  to  invade  the  spinal  canal 
and  compress  the  cord  (Fig.  54).  It  is  very  unusual  for 
one  to  be  amenable  to  surgical  treatment,  but  Davies- 
Colley  succeeded  in  removing  one,  and  the  patient,  who 
was  paraplegic,  recovered  motion  and  sensation. 

Secondary  deposits  of  sarcoma  and  cancer  occur  with 
tolerable  frequency  in  the  spine  ;  and  it  is  not  an  uncom- 
mon event  for  an  individual  to  come  under  observation 
complaining  of  severe  pain  in  the  vertebral  column,  which 
may  or  may  not  be  accompanied  by  a  local  swelling,  proved 
by  careful  investigation  to  be  due  to  a  secondary  deposit 
of  malignant  disease.  In  some  of  these  cases  the  primary 
source  of  the  disease  was  not  known  to  exist  until  the 
"  pain  in  the  back "  led  to  the  examination.  In  one  in- 
structive case  mentioned  by  Horsley  he  actually  operated 
on  a  spine  for  severe  paraplegia,  and  discovered  tumour- 
tissue  in  the  arches  and  spine  of  the  vertebra.  Examina- 
tion determined  it  to  be  thyroid-gland  tissue,  and  the 
patient  had  a  goitre.  There  is  one  aspect  of  secondary 
malignant  disease  of  the  spine  which  needs  consideration. 
When  a  deposit  of  sarcoma  occupies  bone,  it  softens  the 
texture   of  the   bone  ;  when  this  happens  in  the  body  of  a 


SARCOMAS   OF  BONES 


93 


vertebra,  especially  of  the  lumbar  set,  the  superincumbent 
weight  will  gradually  compress  and  slowly  efface  the 
affected  centrum.  In  some  cases  this  is  so  complete  that 
the  intervertebral  discs  formerly  separated  by  the  diseased 
vertebra  will  come  into  apposition  (Fig.  55). 


^  . — 


Fig.  55. — A  portion  of   the  lumbar  spine  infiltrated  with  malignant  disease 
slowly  absorbed  till  intervertebral  discs  came  into  apposition. 


The  pain  which  is  set  up  by  this  slow  "  settling "  of 
the  column  is  very  great,  and  may  often  be  described  as 
agonizing.  I  have  noted  its  occurrence  in  the  cervical  as 
well  as  in  the  lumbar  segments  of  the  vertebral  column. 

Barthauer,  "  Ueber  die  Extirpation  des  Calcaneus,  nebst  Beschreibung 
eines  Falles  von  centralem  Sarkom  des  Calcaneus,  welcher  durch  Extir- 
pation des  Calcaneus  geheilt  wurde." — Zeitschr.  f.  Chir.,  Bd.  xxxviii. 
462. 

Berger,  "De  1' Amputation  interscapulo-thoracique  dans  le  Traitement  des 
Jumeurs  malignes  de  I'Extremite  superieure  de  I'Humerus." — Reo.  de 
CTJr.,  1898,  xviii.  861. 

Bland-Sutton,  J.,  "  On  a  Case  in  which  the  Upper  Half  of  the  Fibula  was 
excised  for  a  Sarcoma."— -Srft  Med.  Journ.,  1896.  i.  1086. 


94  CONNECTIVE-TISSUE    TUMOURS 

Davies-CoUey,  N.,  "  A  Case  of  Fusiform  Sarcoma  of  LaminEe  of  Dorsal 
VertebrEe  :  Pressure  upon  Spinal  Cord;  Eacbiotoray  ;  Cure." — Trails. 
Clin.  Soc,  1892,  xsv.  163. 

Eve,  F.  S.,  "  Specimen  of  Central  Fibro-Sarcoroa  expanding  Tibia,  accom- 
panied by  extreme  Cystic  Degeneration ;  with  remarks  on  the  Relation 
of  Injuiy  and  Inflammation  to  the  production  of  Sarcoma  of  the 
Bones." — Trans.  Path.  Sue.,  1S88,  xxxix.  273. 

Hutchinson,  J.,  jim.,  "Two  Cases  of  Adenoma  of  the  Palate,  with  ex- 
ceptional  Clinical   Features." — Trans.  Path.   Soc,    1886,  xxxvii.   490. 

Keen,  W.  W.,  "Resection  of  the  Sternum  for  Tumours,  with  report  of 
two  Cases  and  a  table  of  seventeen  previously  reported  Cases." — Med. 
and  Surg.   Meporter,    1897,  Ixxvi.  385. 

Keen,  W.  W.,  and  Da  Costa,  J.  C,  "A  Case  of  Interilio-Abdominal  Amputation 
for  Sarcoma  of  the  Ilium,  and  a  synopsis  of  previously  recorded 
Cases." — Internat.  Clinics,  vol.  iv.,  13th  series. 

Moore,  Chas.  H.,  "  Cranio-Facial  Enchondroma." — Trans.  Path.  Soc,  1868, 
xix.   332. 

von  Nasse,  D.,  '  Die  Geschwiilste  der  Speicheldriisen  und  verwandte 
Tumoren  des  Kropfes.",^ — Aroh.  f.  klin.  Chir.  (Langenbeck),  1892, 
xliv.  233. 

Paget,  S.,  "Tumours  of   the  Palate."— rr««5.  Path.  Soc,  1886,  xxxviii.  348. 
Parker,  Robert  William,    "  Sequel  to   a   Case  •  of    Removal  of  Right  Patella 

for  Primary  Sarcoma  :  Recurrence  after  six  years  in  the  Iliac  Glands ; 

DQ&ih."— Trans.  Clin.  Soc,  1896,  xxix.  22. 

Quenu  et  Longuet,    "Tumours    du    Squelette    thoracique." — Pev.   de    Chir., 

1898,  xviii.    365. 
von    Volkmann,     Rudolf,    "  Ueber    endotheliale    Geschwiilste,   zugleich   ein 

Beitrag     zu    den      Speicheldriisen     und     Gaumentumoren."  —  Peutsche 

Zeitschr.  f.   Chir.,  1895.  xli.  1. 
Webber,  H.  W.,    "A  Case   of  Sarcoma  of  the  Sixth  Rib  in  the   removal  of 

which    the     Pericardial    and     Left     Pleural     Cavities     were      opened; 

Vieco^Qxy."— Lancet,  1900,  ii.  1347. 


CHAPTER  VIII 
SARCOMAS  OF  GLANDULAR  ORGANS 

Compound   glandular   organs   like  tlie  kidney   and  prostate 
are  liable  to  sarcomas  at  all  ages,  but  these  are  more  frequent 


Fig.  56. — Bladder  and  urethra  in  section  :  the  prostate  is  occupied 
by  a  sarcoma.     (From  a  hoy  aged  7  years.) 

in  the  early  years  of  life.  This  is  well  shown  by  sarcoma 
of  the  prostate :  nearly  half  the  recorded  cases  occurred  in 
the  first   ten   years  of  life,  many  of  them    during  infancy. 

95 


96  GONNEOTIVE-TLSSUE    TUMOURS 

Proust  and  Vian  collected  the  records  of  thirty-four  ex- 
amples of  this  disease ;  the  youngest  was  an  infant  of  5 
months,  the  eldest  a  man  of  73  years.  Of  these  thirty- 
four  patients,  fifteen  were  under  8  years  of  age. 

As  is  the  case  with  sarcoma  generally,  the  onset  and 
early  course  of  the  disease  is  very  insidious  and  painless, 
until  the  tumour  interferes  with  some  important  function. 
In  the  case  of  the  prostate,  it  is  the  interference  with 
micturition  which  draws  attention  to  the  existence  of  a 
tumour.  In  a  boy  under  my  own  care  the  prostate  was 
converted  into  a  large  mass  which  pushed  the  bladder  high 
in  the  belly.  The  retention  was  caused  by  a  bud-like 
process  of  the  tumour  which  acted  as  a  valve  at  the  vesical 
orifice  of  the  urethra.     (Fig.  56.) 

The  kidney  is  more  frequently  the  seat  of  sarcoma 
than  the  prostate,  but  the  disease  shows  the  same  relative 
frequency  in  early  life.  The  type  of  sarcoma  which  grows 
in  the  kidneys  of  infants  and  children  differs  from  that  of 
adults. 

Renal  sarcomas  of  infants. — These  originate  in  the  con- 
nective tissue  of  the  renal  sinus,  and  gradually  distend 
the  cortex  until  the  tumour  is  surrounded  by  a  thin 
capsule  formed  of  expanded  secreting  tissue  of  the  kidney. 
On  this  account  these  tumours  are  described  as  being 
encapsuled,  but  it  is  a  spurious  encapsulation  formed 
partly  by  renal  tissue  and  in  part  by  the  true  capsule 
of  the  kidney.  (Fig.  57.)  On  section,  such  sarcomas  are 
yellowish-white,  and  the  cut  surface  is  often  dotted  with 
groups  of  small  cavities  due  to  secondary  changes,  especially 
when  the  tumour  is  very  large. 

The  base  of  such  sarcomas  is  connective  tissue  con- 
taining cells  of  various  shape  and  size ;  some  are  round  or 
oat-shaped,  and  others  are  spindles.  In  a  fair  proportion 
of  specimens  many  of  the  spindle  cells  present  the  cross 
striation  so  characteristic  of  the  fibres  of  voluntary  muscle, 
and  they  lack  a  sarcolemma.  When  these  cells  are  present 
the  tumour  is  sometimes  termed  a  myo-sarcoma. 

A  careful  microscopic  study  of  these  tumours,  as  well 
as  a  critical  analysis  of  the  descriptions  published  by 
others,    indicates    that    when    the    striped    cells    are    very 


SARCOMAS   OF  GLANDULAR   ORGANS  97 

abundant  the  tubules  are,  as  a  rule,  absent.  In  examples 
containing  many  tubules  (Fig.  58),  as  well  as  those  in 
which  striped  spindles  are  numerous,  the  round,  oat- 
shaped,  and  spindle  sarcoma  cells  are  equally  abundant. 
It  has  been  suggested  by  Paul  that,  as  the  most  typical 
myo-sarcomas  are  more  sharply  delimited  from  the  other 
varieties,  the  tubular  elements  may  be  derived  from  the 
kidney.  I  did  not  at  first  acquiesce  in  this  view,  but  a 
more   extended   inquiry   leads   me   to   accept  it.     This  is  a 


Fig.  57. — Renal  sarcoma  in  section  ;  removed  from  a  child  aged  20  months. 

matter  worth  consideration,  because  a  study  of  the  foetal 
kidney  demonstrates  very  clearly  that  the  renal  sarcomas 
of  infancy  arise  in  the  connective  tissue  of  the  renal  sinus. 
The  epithelial  cylinders  are  due  to  the  entanglement  of 
uriniferous  tubules,  in  consequence  of  the  sarcoma  invading 
the  cortex,  whilst  the  striated  spindles  are  derived  from 
the  muscle-tissue  of  the  renal  pelvis,  which  is  an  expansion 
of  the  hollow  muscle  known  as  the  ureter. 

These  studies  demonstrate  in  no  uncertain  way  that 
renal  sarcomas  of  infants  are  extrinsic  in  origin,  and 
strictly  non-renal.  This  view  is  now  held  by  all  who 
have  carefully  looked  into  the  matter ;  and  it  is  worth 
mention  that  in  1857  van  der  Byl  exhibited  at  the  Patho- 

H 


98 


G0NNEGTLVE-TI8SUE    TUMOURS 


logical  Society,  London,  a  large  renal  tumour,  from  a 
boy  aged  8  years,  which  measured  82-5  cm.  (33  inches)  and 
weighed  31  pounds ;  and  in  the  description  of  the  specimen 
in  the  catalogue  of  the  Middlesex  Hospital  Museum,  it  is 


Fig.  58. — Microscopic  characters  of  a  renarsarcoma.   (From  an'infant  of  20  months.) 


definitely  stated  that  the  growth  appears  to  have  sprung 
from  the  concavity  of  the  kidney,  and  a  narrow  band  of 
renal  tissue  can  be  traced  round  a  great  part  of  the  circum- 
ference of  the  kidney.  The  general  appearance  of  this  boy 
in  such  dreadful  circumstances  is  shown  in  Fig.  59.     It  is 


8ABG0MAS  OF  GLANDULAR  ORGANS 


99 


characteristic  of  these  sarcomas  that  the  ureter  is  rarely 
obstructed.  This  extraordinary  freedom  of  the  ureter  from 
invasion  explains  the  rarity  of  hsematuria  in  such  cases, 
and,  perhaps,  what  is  otherwise  remarkable,  the  painless- 
ness of  these  tumours  in  children,  for  there  is  no  pressure 


,vy^T«/c 


Fig.  59. — A  boy  aged  8  years  with  a  renal  sarcoma  which  weighed 
31  pounds. 

from  accumulated  urine.  A  child  with  a  very  large 
renal  sarcoma  has  been  absolutely  free  from  pain,  and 
amusing  himself  with  his  playmates  in  the  garden  three 
days  before  he  died.  Indeed,  many  mothers,  when  the 
gravity   of  a  renal    tumour   of   this    kind    is   explained    to 


100  GONNEGTIYE-TISBUE    TUMOURS 

them,  will  express  their  astonishment  that  a  child,  apparently 
in  excellent  health  and  spirits,  could  be  in  such  serious 
straits  as  the  surgeon  would  have  them  believe. 

Though  the  ureter  so  constantl}^  escapes  invasion,  yet 
the  veins  are  always  implicated;  and  this  constitutes  one 
of  the  most  peculiar  as  well  as  most  dangerous  features  of 
renal  sarcomas  in  children.'  The  tumour  tissue  extends 
into  the  renal  vein,  and  often  projects  and  even  runs  for 
a  long  distance  into  the  inferior  vena  cava ;  portions  are 
detached  and  carried  to  the  pulmonary  circulation,  and 
are  arrested  in  the  capillaries  of  the  lung  and  originate 
secondary  deposits.  The  intravenous  apex  of  such  an  out- 
runner is  usually  cone-shaped  and  smooth.  Occasionally  a 
large  fragment  is  detached,  and  this  has  been  known  to 
block  the  right  auriculo-ventricular  orifice  (Osier).  Such  a 
gross  embolus  is  uncommon.  Plugging  of  the  vena  cava 
by  an  outrunner  is  by  no  means  rare,  and  gives  rise  to 
oedema  of  the  lower  limbs.  In  a  case  under  my  own  care 
the  inferior  vena  cava  was  completely  obstructed  from  its 
origin  to  its  termination  by  a  sarcomatous  extension  of 
this  kind. 

It  is  a  singular  and  well-established  fact  that  when 
certain  of  the  paired  viscera,  such  as  the  kidneys,  ovaries, 
eyeballs,  and  crura  cerebri,  are  in  early  life  attacked 
by  sarcomas,  in  a  very  large  proportion  of  cases, 
perhaps  half  the  number,  the  disease  is  bilateral.  In 
relation  to  this  matter.  Abbe  recorded  a  very  important 
observation.  He  successfully  extirpated  a  kidney  for  sar- 
coma in  a  child  14  months  old.  Four  and  a  half  years 
later  the  little  patient  again  came  under  his  care  with  a 
sarcoma  in  the  remaining  kidney.  In  1893  I  collected 
and  tabulated  in  the  first  edition  of  this  book  twenty-one 
complete  records  of  renal  sarcoma  in  infancy  which  had 
been  submitted  to  nephrectomy.  In  the  list  of  twenty-one 
cases,  twelve  patients  died  as  a  result  of  the  operation ; 
of  those  which  recovered,  all  died  of  recurrence  within  a 
year.  Since  the  publication  of  that  table  a  large  amount 
of  interest  has  been  aroused  in  the  question  of  the 
results  of  nephrectomy  for  sarcoma,  and  it  is  now  an  easy 
matter   to    collect    a   hundred    records.     The  analysis   of  a 


SAUGOMAS   OF  GLANDULAR   ORGANS 


101 


large  number  of  these  reports  sliows  that  nephrectomy  for 
renal  sarcomas  in  children  under  6  years  of  age  has  a 
mortality  of  over  50  per  cent.  Of  the  fifty  that  recover, 
forty-five  die  from  recurrence  at  periods  varying  from 
two  months  to  a  year.  In  the  remaining  five,  life  may  be 
prolonged,  as  shown  in  the  adjoining  table : — • 

RENAL   SARCOMAS   IN   INFANTS 
Table  of  cases  in  which  life  mas  prolan r/ecl  beyond  one  year  by  nephrectomy 


Reporter 

Age 

Result 

Hicquet    .  . 
Schmidt   .  . 
Abbe   .... 
Abbe    .... 

Malcolm   .  . 

6  months 
6  months 
2  years 
1  yr.  2  mths. 

If  years 

Died  li  years  after  operation.  {Acad.  Roy.  de 
Med.^de  Belgique,  Jan.  28,  1882.) 

Alive  and  well  thre  •  years  later.  (Dr.  Emily 
Lewi,  Arch,  of  Pediatrics,  xiri.  97.) 

Alive  and  well  five  years  later.  {Ann.  of  Sury., 
189i.) 

Patient  died  4 J  years  later  from  sarcoma  in  re- 
maining kidney.  {Ann.  if  Surg.,  1894  and 
1897.) 

Alive  and  well  10  years  later.  {Trans.  Clin.  Soc, 
xxvii.  94,  and  private  letter.) 

It  is  very  certain  that  a  child  with  a  renal  sarcoma  runs 
an  enormous  risk  of  losing  its  life  when  submitted  to 
nephrectomy,  and  at  the  same  time  the  chances  of  pro- 
longing life  are  more  slender  than  in  any  other  surgical 
operation.  It  must,  however,  be  borne  in  mind  that  the 
disease  is  surely  fatal  within  a  very  limited  period  when 
allowed  to  run  its  own  course. 

Renal  sarcomas  of  adults. — These  differ  in  many  impor- 
tant particulars  from  the  sarcomas  of  infancy.  In  the  first 
place,  a  sarcoma  in  the  adult  arises  in  the  cortex,  usually 
in  connexion  with  the  capside,  and  then  gradually  invades 
the  true  tissue  of  the  kidney.  The  relation  of  renal  sar- 
comas to  the  capsule  is  of  some  importance,  because 
similar  tumours  arise  in  the  connective  tissue  in  which  the 
kidney  is  embedded  ;  these  are  perirenal  sarcomas,  and,  as 
far  as  my  observations  go,  this  is  a  more  frequent  position 
for  them  than  those  which  we  term  renal  sarcomas.  A 
careful  comparison  of  these  tumours  leads  me  to  believe 
that,  in   the    adult,   sarcomas    of   the    type    represented    in 


102 


OONJ^EGTIVE-ttSSU:^  TUMOtM 


Fig.  60  have  their  origin  in  the  renal  capsule,  whereas  the 
sarcoma  of  childhood  arises,  as  already  pointed  out,  in  the 
connective  tissue  of  the  renal  sinus.  This  is  a  subject  of 
some  interest,  because  a  critical  comparison  of  the  mode 
of  origin  of  sarcomas  in  viscera  similar  to  the  kidney,  e.g. 
the  spleen,  thyroid  gland,  and  prostate,  shows  that  such 
tumours  are  not  only  uncommon,  but  are  often  closely 
connected  with  the  connective-tissue  investments  of  such 
organs. 


Fig.  60. — A  kidney  in  section  with  a  sarcoma  invading  its  cortex.     From  a  man 
51  years  of  age.     {Museum,  3fiddlesex  Hospital.) 

Treatment. — The  only  available  treatment  for  renal  sar- 
coma is  early  excision  of  the  affected  organ.  This  is  rarely  of 
much  service.  The  mortality  of  the  operation  is  now  very 
small,  but  recurrence  usually  takes  place  within  a  year. 

A  new  interest  was  given  to  malignant  tumours  of  the 
kidney  when  Grawitz  stated  that  many  of  them  occurring 
in  adults  exhibited  the  structure  of  the  zona  fasciculata 
of  the  adrenal.  Grawitz  further  suggested  that  these 
tumours,  now  known  as  hypernephromas,  probably  arose  in 
detached  (ectopic)  pieces  of  the  adrenals  (accessary  adrenals). 

It  has  long  been  known  that  accessary  adrenals  are  found 


SARCOMAS  OF  GLANDULAR  ORGANS 


103 


beneath  the  capsule  of  the  kidney  (Fig.  61),  as  well  as  on  the 
under  surface  of  the  liver ;  they  are  also  found  in  the  retro- 
peritoneal tissue  in  the  course  of  the  spermatic  artery,  in  the 
spermatic  cord,  simulating  fatty  tumours  (Andrewes). 

In  addition  to  the  topographical  and  histologic  features  of 
these  tumours,  stress  is  laid  on  the  presence  of  glycoo-en  in 
the  cells,  this  being  an  additional  support  to  the  view  that 
such  tumours  arise  in  embryonic  tissue. 


ACCESSARY    ,   DRE 


/^ 


Fig.  61. — Au  accessary  adrenal  beneath  the  capsule  of  the  kidney. 
{Maseum,  Royal   College  of  Surc/eonti.) 

It  has  long  been  known  that  the  adrenal  may  be  trans- 
formed into  a  large  tumour  in  the  same  way  that  the 
thyroid  gland  becomes  a  goitre,  and  the  analogy  is  so  striking 
that  Yirchow  years  ago  proposed  for  adrenal  tumours  the 
term  "struma  suprarenalis."  In  recent  years  this  analogy 
has  been  further  justified  by  the  fact  that  some  of  these 
adrenal  tumours,  as  well  as  those  which  arise  beneath  the 
capsule  of  the  kidney,  and  exhibit  the  adrenal  structure, 
disseminate    and     mimic     the     extraordinary    phenomenon 


104 


GONNEOTiVE-TISSUE  TUMOTJUS 


known  as  "  general  thyroidal  malignancy,"  in  which  tumours, 
exhibiting  all  the  microscopic  features  of  thyroid  gland, 
appear  in  the  bones,  especially  the  skull,  vertebrae,  and 
femur,  as  well  as  in  the  viscera,  in  association  with  what 
appears  to  be  a  simple  adenoma  of  the  thyroid  gland. 

Whatever  view  may  be  taken  of  the  tissue  in  which 
these  tumours  arise,  it  is  quite  certain  that  they  exhibit 
peculiarities  of  structure  which  distinguish  them  from  the 


Fig.  62. — Sarcoma  of  the  kiduey  supposed  to  arise  from  an  adrenal  "rest." 
Removed  from  a  woman  aged  42  years,  during  pregnancy.  She  was  in 
good  health  five  years  later,   in   spite   of  having  borne  a   child. 


ordinary  round-  and  spindle-celled  species  of  sarcomas.  That 
they  are  malignant  is  equally  beyond  question,  for  they 
recur  after  removal  and  give  rise  to  secondary  nodules  in 
the  lungs.  The  frequency  with  which  the  lungs  are  infected 
is  due  to  the  primary  tumour  invading  the  renal  vein. 

Though  these  tumours  are  very  vascular,  and  their 
central  parts  often  destroyed  by  extravasation  of  blood,  they 
do   not   give   rise   to   hsematuria   because  the   tumour   does 


SAUGOMAS  OF  GLANDULAR  ORGANS  105 

not  invade  the  renal  pelvis.  This  is  the  most  striking 
fact  in  their  clinical  history. 

Recently  doubt  has  been  thrown  on  the  origin  of  hyper- 
nephromas from  islands  of  adrenal  tissue,  especially  by 
Stoerk.  He  points  out  that  these  tumours  do  not  occur  in 
the  adrenal  itself;  also  that  adrenal  rests  are  most  frequently 
found  in  the  upper  pole  of  the  kidney  and  hypernephromas 
occur  more  commonly  in  the  lower  half  of  this  organ. 
Adrenal  rests  occur  in  the  liver,  but  hypernephromas  have 
not  been  detected  in  hepatic  tissue. 

The  opinion  is  gaining  ground  that  the  majority  of 
tumours  classed  as  hypernephromas  are  carcinomas  arising 
in  the  cells  of  the  renal  tubules,  and  I  share  in  this  opinion. 
The  classification  of  malignant  renal  tumours  is  a  difficult 
matter. 

van  der  Byl,  "  Large  Cancerous  Growth  of  the  Kidney  in  a  Child." — Trans. 

Path.  Soc,  1856,  vii.  268. 
Edington,  G.  H.,  Myxo-Sarcoma  of  the  Prostate  in  a  Child  aged  1  year  and 

U  months— Brit.  Med.  Journ.,  IS09,  ii.  754. 
Trotter,  W.,   "  On  Hypernephroma." — Lancet,  1909,  i.  1581. 


CHAPTER  IX 

TUMOURS  OF  THE  ADRENAL  (SUPRARENAL 
CAPSULE) 

The  adrenal  is  liable  to  tumours,  many  of  which,  have 
been  described  as  sarcomas,  some  as  carcinomas,  and  others 
as  hypernephromas.  The  adrenals,  like  other  paired  organs, 
are  subject  to  malignant  tumours  at  two  distinct  periods : 
childhood  and  adult  life. 

Adrenal  tumours  in  children. —  Our  first  knowledge  ot 
these  tumours,  in  the  main  described  as  sarcomas,  was 
derived  from  post  -  mortem  observation.  This  evidence 
showed  that  such  tumours  were  rare,  that  they  occurred 
in  the  early  years  of  life,  usually  attacked  both  organs,  and 
sometimes  attained  the  size  of  coco-nuts.  It  was  also 
established  that  they  gave  rise  to  secondary  deposits, 
especially  in  the  liver. 

Observers  like  Greenhow,  Hale  White,  Dalton,  Ogle, 
Dickinson,  Colcott  Fox  and  others  not  only  gave  careful 
descriptions  of»the  tumours,  but  some  of  them  drew  attention 
to  the  peculiar  coloration  of  the  skin,  unlike  the  bronzing 
of  Addison's  disease,  the  abnormal  development  of  hair,  and 
in  some  instances  precocious  development  of  the  sexual 
organs. 

Many  carefully  described  examples  have  since  been 
published.  Bulloch  and  Sequeira  have  collected  twelve  cases 
in  which  the  ages  of  the  patients  varied  from  1  to  14  years. 
The  majority  of  the  children  were  girls  under  4  years. 

This  combination  of  pigmentation,  precocious  develop- 
ment of  the  sexual  organs,  and  a  tumour  of  the  adrenal 
is  so  remarkable  that  it  is  necessary  to  give  brief  details 
of  two  well-marked  examples. 

Dr.  Sequeira's  patient,  aged  11  years,  looked  like  a 
stout  little   woman   of  40.     She   was   four   and  a  half  feet 

106 


TUMOmS  OF  THE  ADRENAL  1('7 

high  and  weighed  eighty-seven  pounds,  a  brunette,  with 
coarse  skin,  and  a  copious  development  of  hair  on  the 
lips  and  chin.  The  pubic  region  and  axillae  were  covered 
with  long  hair,  and  her  mammse  resembled  those  of  a 
sexually  mature  woman.  The  abdomen  was  distended  with 
fluid  (hydroperitoneum),  and  a  large  tumour  could  be  felt 
in  the  left  hypochondrium.  She  died  a  few  months  after 
coming  under  observation.  The  left  adrenal  was  replaced 
by  a  tumour  weighing  three  pounds.  The  liver  and  lungs 
contained  secondary  deposits.  The  microscopic  structure 
of  the  tumour  and  the  secondary  deposits  resembled  that  of 
the  cortical  portion  of  the  adrenal.  This  girl  up  to  the  age 
of  10  years  had  been  to  all  outward  appearance  normal. 

A  case  recorded  by  Adams  is  equally  remarkable. 
The  patient,  a  boy  aged  14  years,  developed  normally  to 
the  tenth  year,  then  he  became  pubic,  this  change  being 
accompanied  by  marked  muscular  development,  and  the 
growth  of  a  beard  so  abundant  that  he  had  to  be  shaved 
almost  daily.  His  appearance  was  that  of  a  sturdy  little 
man.  His  complexion  grew  dusky,  and  a  tumour  became 
obvious  in  his  abdomen.  An  attempt  was  made  to  remove 
the  tumour,  but  it  proved  inoperable :  the  boy  died  eighteen 
months  later.  The  tumour  weighed  eight  and  a  half  pounds 
and  adhered  to  the  left  kidney.  No  trace  of  the  left  adrenal 
could  be  found.  The  liver  was  thickly  dotted  with  secondary 
deposits,  some  of  which  were  as  big  as  walnuts.  Microscopi- 
cally the  tumour  presented  an  alveolar  arrangement,  and  was 
regarded  as  a  hypernephroma,  taking  its  origin  in  the  cortex 
of  the  left  adrenal. 

These  important  observations  indicate  that  the  cortex 
of  the  adrenal  is  probably  connected  in  some  way  with 
the  growth  of  the  body,  and  the  development  of  puberty 
and  sexual  maturity.  Guthrie  and  Emery,  following  up 
these  observations,  have  pointed  out  that  precocious  obesity 
is  sometimes  associated  with  hypernephromas  and  forms  a 
clinical  feature  as  striking  as  precocious  puberty.  Parkes 
Weber  considers  that  the  extraordinary  development  of 
children  associated  with  the  presence  of  a  h3^pernephroma 
presents  two  types,  (1)  the  precociously  obese  type  (Fig.  63), 
and  (2)   the  muscular  or  "  infant  Hercules "  type. 


108 


CONNEGTIVE-TISSUE    TUMOUliS 


From  a  careful  consideration  of  the  subject,  Guthrie  and 
Emery  come  to  the  conckision  that  precocious  physical  de- 
velopment, sexual  and  somatic,  may  be  due  to  tumours  or 


Fig.  63. — A  toy  4|  years  of  age,  the  subject  of  precocious  obesity  associated 
with  a  hypernephroma  and  acute  tuberculosis.  He  resembles  in  miniature 
"a  burly  brewer's  drayman"  {Guthrie). 


TUMOURS   OF   THE   ADRENAL  109 

hypertrophy  of  the  pituitary  and  pineal  glands,  and  of  the 
adrenal  cortex.  Premature  hirsuties  occurs  in  practically 
all  cases  of  premature  physical  development,  but  is  not 
necessarily  associated  with  other  signs  of  sexual  maturity. 
The  obese  type  of  precocious  development  may  occur  in  boys 
and  girls,  but  the  muscular  type  is  confined  to  boys.  It  is 
necessary  to  remember  that  precocious  development,  sexual 
and  somatic,  may  be  unassociated  with  any  obvious  lesion  of 
glandular  organs. 

Adrenal  tumours  in  adults. — Malignant  tumours  arise  in 
the  adrenals  of  adult  men  and  women :  they  sometimes  attack 
both  organs,  and  display  the  usual  features  of  malignancy, 
for  they  grow  rapidly,  disseminate,  and  quickly  destroy  life. 

Adrenal  tumours  in  adults,  as  in  children,  are  sometimes 
associated  with  unusual  hairiness  (hirsuties).  Thornton 
recorded  a  case  of  this  kind.  He  removed  from  a  lady  3G 
years  of  age  a  large  tumour  of  the  left  adrenal.  The  patient 
was  covered  "  with  long,  silky  hair,  and  had  to  shave 
her  face  just  like  a  hairy  man."  The  tumour  was  removed 
in  April  1889,  and  in  November  of  the  same  year  she 
wrote  that  she  was  like  her  old  self  and  had  "  all  the 
external  appearances  of  other  women."  The  tumour 
removed  from  this  patient  is  preserved  in  the  museum 
of  the  Royal  College  of  Surgeons  of  England. 

Adams,  C.  E.,  "A  Case  of  Precocious  Development  associated  with  a  Tumour 

of  the  Suprarenal  Body."— Travis.  PatJi.  Soe.,  1905,  Ivi.  208  ^ 

Bulloch,  W.,  and  Sequeira,  H.,  "On  the  Relations  of  the  Suprarenal  Capsules 

to  the  Sexual  Organs." — Trans.  Path.  Soc,  1905,  Ivi.  189. 
Dalton,  N.,  "  Infiltrating  Growth  in  Liver  and   Suprarenal  Capsule." — Trans. 

Path.  Snc,  1885,  xxxvi.    247. 
Greenhow,  E.  H.,    "  Cancer  of  One  Suprarenal  Capsule." — Trans.  Path.  Soo., 

1867,  xviii.  260. 
Guthrie,  L.,  and  Emery,  W.  d'Este,  "  Precocious  Obesity,  Premature  Sexual 

and  Physical  Development  and  Hirsuties  in  relation  to  Hypernephroma 

and  other  Morbid  Conditions." — Trans.  Clin.  Soc,  1907,  xl.  175. 
Ogle,  John  W.,  "  Unusually  Large  Mass  of  Carcino.natous  Deposit  in  one  of 

the  Suprarenal  Capsules  of  a  Child." — Trans.  Path.  Soc,  1865,  xvi.  250. 
Thornton,  J.  Knowsley,  "  Abdominal  Nephrectomy  for  Large  Sarcoma  of  the 

Left  Suprarenal  Capsule:  Recovery." — Trans.  Clin.  Soc,  1890,  xxiii.  150. 
West,     Samuel,      "  Primary     Sarcoma    of    the     Suprarenal    Capsule,    with 

Secondary   Growth  in  the  Lung."— Trans.  Path.  Soc,  1879,  xxx   419. 
White,    W.    Hale,    "  Sarcoma    of   Suprarenal  Capsule " — Trans.    Path.    Soc, 

1885,   xxxvi.  464. 


CHAPTER   X 
PIGMENTED  TUMOURS 

This  chapter  will  be  devoted  to  tlie  consideration  of 
melanomas  and  pigmented  conditions  such  as  the  small 
red  plaques  on  the  skin  known  as  "  De  Morgan  spots," 
ochronosis,  chloroma  (green  cancer),  and  xanthoma. 

MELANOSIS 

In  the  majority  of  mammals  there  are  certain  epithelial 
and  connective  tissues  which  normally  contain  pigment. 
Among  pigmented  tissues  the  skin  and  the  epithelial  layer 
of  the  retina  hold  the  first  place.  In  skin  the  pigment  is 
chiefly  contained  in  the  deeper  layers  of  the  rete  mucosum ; 
and  hair,  being  derived  from  the  cells  of  this  layer,  is 
pigmented  also.  In  many  mammals  other  tissues  contain 
pigment,  such  as  the  mucous  membrane  of  the  roof  of  the 
mouth  of  the  dog,  and  the  blue  coloration  of  the  vaginal 
mucous  membrane  of  the  vervet  monkey. 

In  man  the  amount  of  pigment  varies  greatly,  so  that 
we  may  pass  gradually  from  individuals  whose  skins  are 
intensely  black  to  others  who  have  no  trace  of  cutaneous 
pigment. 

It  is  a  noteworthy  fact  that  animals  with  no  pigment  in 
the  skin  also  lack  pigment  in  the  uveal  tract  of  the  eyeball. 
A  familiar  example  of  this  is  the  white  rabbit  with  pink  eyes. 
Such  a  condition  is  termed  albinism,  and  colourless  animals, 
or  albinos,  occur  among  all  classes  of  animals,  vertebrate 
and  invertebrate.  Excessive  development  of  black  pigment 
in  the  skin  is  known  as  melanism ;  this  is  much  rarer  than 
albinism. 

Abnormal  distribution  of  pigment  is  common ;  in  man  it 
gives  rise  to  the  condition  termed  leucoderma  when  it  affects 
the  skin,  and  unequal  distribution  of  pigment  in  the  retina  is 

110 


MELANOSIS  111 

known  as  retinitis  pigmentosa.  Irregular  patches  of  black 
in  the  skins  of  horses  cause  them  to  be  described  as  piebald, 
and  when  disseminated  in  small  dots  and  irregular  tracts  they 
are  said  to  be  grey. 

In  the  white  races  of  men  the  pigment  granules  are 
almost  entirely  confined  to  the  cells  of  the  rete  mucosum,  but 
when  the  pigmentation  is  very  marked  it  will  be  found 
distributed  in  the  other  tissues  of  the  skin.  The  pigment,  or 
melanin  as  it  is  called,  lies  within  the  cells  in  the  form  either 
of  black   or   of  brown  granules,  or  they  may  be   uniformly 


Fig.  64. — Anterior  portion  of  a  dace ;  each  black  spot  contains  a  central 
white  dot  representing  au  encysted  parasite. 

stained  by  it.  It  is  stated  that  white  skin  transplanted  on  to 
a  negro  soon  becomes  pigmented,  and  that  when  the  skin  of 
a  negro  is  grafted  on  to  a  white  man  it  undergoes  depig- 
mentation. It  has  long  been  known  that  leucocytes  carry 
pigment. 

In  amphibians  and  fishes  pigment  occurs  in  the  branch- 
ing cells  (Deiter's  cells)  situated  beneath  the  epidermis. 
These  cells  are  filled  with  black  melanin  granules,  obscuring 
the  nucleus.  On  exposure  to  light  these  protoplasmic 
processes  retract,  and  the  pigment  is  concentrated  in  the 
cell  body,  but  when  kept  in  the  dark  the  processes  are 
protruded  and  the  pigment  is  diffused  in  the  surrounding 
structures. 

The  most  remarkable  example  of  pigment-formation  is 
found  in  cuttle-fishes  (octopus  and  sepia).      These  inverte- 


112  G0NNEGTIVE-TI88UE    TUMOURS 

brates  possess  an  ink-bag  from  whicb,  when  irritated,  they 
eject  a  black  pigment  (sepia)  in  such  abundance  as  to  colour 
the  surrounding  water  to  the  extent  of  a  cubic  yard  or 
more,  and  under  cover  of  this  dark  cloud  they  escape  from 
their  enemies. 

Melanosis  is  sometimes  produced  by  parasites.  This 
variety  of  melanism  is  rarely  seen  in  man,  but  is  fairly 
frequent  in  dogs  and  fishes  (Fig.  64). 

Pathological  pigmentation  in  its  most  serious  form  is 
seen  in  connexion  with  tumours  known  as  melanomas. 

Melanomas. — Melanomas  are  rare  tumours,  which  occur 
in  those  regions  of  the  body  where  pigment  is  found 
normally,  namely,  the  skin  and  the  pigmented  tissues  of 
the  eye. 

Melanomas  of  the  skin  arise  in  abnormal  pigmented  areas 
such  as  moles  and  warts,  and  especially  in  patches  of  pig- 
ment sometimes  found  near  the  matrix  of  the  nails  on 
the  fingers  and  toes,  and  occasionally  they  follow  injuries 
of  the  skin. 

We  have  been  accustomed  to   classify  these   malignant 
tumours  roughly  as  round-celled  or  spindle-celled  sarcomas 
according  to  the  prevailing  type  of  cell  visible  in  magnified 
sections ;  but  there  is  another,  but  very  rare,  kind  detected 
by  Collins,  which  arises  from  the  glandular  epithelial  cells  in 
the  ciliary  body.     Ribbert  has  published  some   observations 
(1897)  which  add  great  interest    to   these   tumours.     A¥hen 
the  choroidal  tumours   are  examined   by  teasing,  the   cells 
assume  the  stellate  forms  Avith  which  most  of  us  are  familiar 
in  the  pigment  cells  so  abundant  in  the  skin  of  frogs  and 
other   amphibians,  and  particularly  in   cuttle-fishes.     These 
are    known    as    chromatophores,   and    Ribbert   would   have 
us  so  regard'  these  cells  in  the  choroid  and  in  the  skin,  and 
he  even  suggests  that  melanomas   might   be   appropriately 
termed  chromatophoromas.    In  regard  to  this,  it  is  necessary 
to  point  out  that  the  black  pigment  (melanin)  in  the  pigment 
cells  of  vertebrates  only  agrees  (according  to  MacMunn)  with 
that  of  invertebrates  in   the   common   attribute — blacknes;! 
The  interest  of  Ribbert's  observations  lies  in  the  fact  that  in 
secondary  nodules   of  choroidal  tumours  found  in  the  liver 
and    brain,    the    cells  were    identical   with   the    chromato- 


MELANOMAS 


113 


phores  which  are  so  characteristic  of  the  lamina  fusca  element 
of  the  choroid. 

The  amount  of  melanin  present  in  pigmented  tumours 
varies  greatly ;  in  some  it  is  so  small  that  the  tissue  takes 
on  merely  a  brown  coloration,  in  others  the  tissues  are 
as  black  as  ink.  The  pigment  particles  are  lodged  in  and 
among    the    cells    of   the    tumours,   even    in    the   walls   of 


Fig.  65. — Pigmented  stellate  cells  from  a  melano -sarcoma.  The  cells  in  the  lower 
part  of  the  figure  are  from  a  secondary  nodule  in  the  liver  ;  the  upper  from 
a  metastatic  nodule  in  tlie  brain.  The  primary  tumour  iu  each  instance  arose 
in  the  choroid.    Teased  specimens  {after  Ribbcrt). 

the  blood-vessels.      Occasionally  the  secondary  nodules  are 
blacker  than  the  primary  tumour. 

Melanin. — This    occurs    as    fine,    irregular,    amorphous 
granules  varying  from  light  brown  to  intense  black.     It  is 
soluble  in  ether,  alkalies,  and  strong  acids,  and  is  bleached  by 
\ 


114  CONNECTIVE-TISSUE    TUMOURS 

chlorine — a  fact  which  is  useful  in  examining  the  microscopic 
features  of  melanomas. 

The  urine  of  patients  with  melanotic  tumours  often 
contains  black  pigment  (melanogen),  usually  in  solution,  but 
occasionally  suspended  in  the  form  of  granules.  The  urine  is 
as  a  rule  clear  when  first  voided,  but  blackens  on  exposure 
to  the  air,  and  becomes  intensely  black  when  submitted  to 
oxidizing  reagents,  e.g.  a  mixture  of  sulphuric  and  hydro- 
chloric acids  to  Avhich  a  few  drops  of  ferric  chloride  have 
been  added. 

A  more  sensitive  test  is  the  addition  of  bromine  water 
to  the  urine,  wdiich  yields  a  yellow  precipitate  turning 
black  on  exposure  to  light.  I  made  several  observations  on 
the  urine  of  patients  suffering  from  melanomas,  in  the  hope 
that  some  opinion  might  be  formed  as  to  the  gravity  of 
the  patient's  condition  according  to  the  amount  of  melanin 
present.  I  am  inclined  to  believe  that  an  abundance  of 
melanin  is  of  the  gravest  import. 

In  the  rare  anomaly  known  as  alkaptonuria  the  urine 
when  passed  is  clear,  then  becomes  brown,  and  finally  black 
on  exposure  to  the  air.     {See  Ochronosis,  p.  120.) 

Primary  melanomas  of  the  skin.  —  These  arise  in  moles, 
especially  the  black  blemish  known  as  navus  spilosus,  and 
in  pigmented  warts. 

A  pigmented  mole  may  remain  quiescent  throughout  a 
very  long  life  and  never  cause  the  least  inconvenience  ;  in 
other  instances,  fortunately  rare,  as  life  advances  the  mole 
ulcerates,  perhaps  bleeds  freely,  and  may  even  partially  heal ; 
but  coincidently  with  the  onset  of  ulceration  the  adjacent 
lymph-glands  enlarge,  become  charged  with  pigment  and 
sarcomatous  tissue,  spaces  filled  with  inky  fluid'  form  in 
them,  and  finally  the  overlying  skin  ulcerates.  The  infection 
may  not  proceed  farther  chan  this ;  recurrent  liaBmorrhage 
from  the  fungating  glands,  or  furious  bleeding  should  a  large 
vein  or  artery  become  broached  by  ulceration,  carries  off  the 
patient.  In  many  cases  the  morbid  material  is  transported 
into  distant  parts,  secondary  knots  form  in  the  liver,  lung, 
kidney,  or  brain,  and  death  arises  from  interference  with 
the  functions  of  these  organs. 

In  other  cases  the  mole,  instead  of  ulcerating,  is  observed 


MELANOMAS 


115 


to  become  more  prominent,  and  finally  forms  a  tumour  of 
some  size  standing  out  prominently  from  the  skin.  In  due 
course  the  lymph-glands  in  anatomical  relation  with  the  part 
from  which  the  tumour  arose  enlarge,  and  secondary  deposits 
occur  in  the  viscera,  bones,  or  skin. 

It  does  not  necessarily  follow  that  in  all  cases  of  melano- 
mas arising  in  moles  secondary  deposits  are  formed  in  the 
viscera.  In  some  cases — which,  however,  are  very  rare — the 
tumour  seems  to  become  mainly  a  source  of  pigment,  largo 
quantities  of  which  enter  the  circulation,  to  be  discharged 
with  the  urine.     Exceptionally  the  skin  assumes  a  dusky  tint. 

Many  melanomas  arise  in  pigmented  warts,  especially  the 
solitary  congenital  kind.  After  middle  life  such  a  wart  may 
grow,  ulcerate,  stink,  cause  the  adjacent  lymph-nodes  to 
enlarge,  and  then  infect  the  system  with  secondary  nodules. 

Melanosis  in  connexion  with  the  fingers  and  toes  assumes 
two  forms :  it  may  occur  as  a  deep  pigmentation  of  the  skin, 
usually  in  the  immediate  neighbourhood  of  the  nail,  often 
involving  the  matrix,  and  even  the  nail  itself;  or  a  small 
pigmented  nodule  will  arise  in  the  nail  matrix  or  in  the 
adjacent  skin,  and  ulcerate,  dissemination  following. 

The  hallux  is  the  digit  most  prone  to  be  attacked  by 
a  melanoma,  and  several  examples  have  been  carefully 
recorded,  most  of  the  patients  being  women.  The  cases 
are  arranged  in  the  following  table : — 


Reporter 

Sex 

Age            Digit 

Referexce 

Fergusson    . 
Hutchinson 
Nunn       .     . 
Lediard  .     . 
Bowlby   .     . 
Barnard  .     . 

M. 
F. 
F. 
F. 
F. 
F. 

36 
60 
50 
40 
55 
60 

Hallux    .     . 
Hallux    .     . 
Fifth  finger 
Index  finger 
Hallux    .     . 
Index  finger 

Lancet,  1857,  i.  290. 

Trans.  Path.  Soc,  viii.  404. 

Ibid.,  xxxi.  299. 

Ibid.,   xxxix.  307. 

Ibid.,  xli.  314. 

Brit.  Med.  Joiirn.,  1902,  i.  457. 

Apart  from  abnormal  deposits  of  pigment  such  as  moles 
and  warts,  melanomas  are  occasionally  found  in  those  parts 
of  the  body  where  the  skin  is  more  deej^ly  pigmented  than 
usual,  namely,  the  external  genitals  in  both  sexes,  and  the 
skin  around  the  anus. 

The  skin  of  the  vulva,  male  genitals,  and  the  anus  contains 
more  pigment  than  other   parts    of    the    body.       Malignant 


116  CONNECTIVE-TISSUE   TUMOURS 

melanoma  of  the  vulva  is  rare.  Holland  collected  37  cases. 
Melanoma  of  the  penis  is  very  rare.  Cases  have  been  reported 
by  Fischer  and  Payr. 

Primary  melanoma  of  mucous  membrane  is  very  rare,  and 
it  is  odd  that  the  recorded  cases  have  been  observed  on  the 
muco-periosteum  of  the  hard  palate.  Treves,  in  recording  an 
example,  reminds  us  of  the  fact  that  the  mucous  membrane 
in  this  situation  is  charged  with  pigment  in  certain  mammals. 
This  is  the  case  Avith  dogs. 

The  theories  relating  to  the  connexion  between  abnormal 
patches  of  pigment,  moles,  and  melanomas  have  recently 
been  carefully  summarised  by  Fox. 

Intra-ocular  melanomas. — The  commonest  situations  of 
these  tumours  are  the  uveal  tract  and  the  lamina  fusca; 
the  seat  of  origin  accounts  for  the  presence  of  pigment. 
Their  distribution  in  these  tissues  is  curious,  for  a  melanoma 
of  the  choroid  is  ten  times  more  common  than  in  the  ciliary 
body,  and  a  pigmented  tumour  of  the  iris  is  excessively  rare; 
moreover,  those  Avhich  arise  in  the  ciliary  body  are  carci- 
nomas. 

Melanomas  of  the  uveal  tract  are  most  frequent  between 
the  fortieth  and  sixtieth  years,  but  they  have  been  observed 
as  early  as  the  fifteenth  and  as  late  as  the  eighty-fourth 
year. 

In  structure  they  may  be  round-celled,  spindle-celled,  or 
mixed-celled,  the  size  of  the  cells  varying  greatly  in  different 
tumours.  The  amount  of  pigment,  too,  in  intra-ocular  melano- 
mas varies  greatly ;  in  some  specimens  it  is  so  abundant  that 
the  tumour  is  coal-black ;  in  others  it  is  only  sufficient  to 
impart  a  grey  tint.  Occasionally  the  pigment  is  so  irregularly 
distributed  that  some  parts  of  it  are  almost  colourless. 

The  tumour  remains  for  a  time  restricted  to  the  interior 
of  the  globe,  but  it  tends  to  escape  therefrom  in  three 
directions :  («)  along  the  course  of  the  venoe  vorticosfe, 
appearing  outside  the  sclerotic  in  the  situations  where  these 
veins  emerge ;  (6)  the  presence  of  the  tumour  leads  to  an 
increase  in  the  intra-ocular  tension,  and  finally  to  sloughing 
of  the  cornea ;  {c)  the  growth  may  invade  the  optic  nerve. 

Melanomas  are  very  apt  to  recur  after  removal,  and  to 
become  disseminated.     The  most  frequent  situation  in  which 


INTBA-OGULAR    MELANOMAS  117 

to  find  secondary  deposits  is  the  liver;  but  any  organ 
may  contain  them,  even  the  bones.  It  is  surprising,  con- 
sidering that  the  eyeball  is  near  to  and  in  such  close  relation 
with  the  brain  by  so  large  a  nerve- trunk  as  the  optic  nerve, 
that  the  brain  should  be  rarely  implicated.  It  is  a  fact  that 
Avhen  the  brain  is  a  seat  of  deposit  this  is  rarely  the  result 
of  extension  along  the  nerve.  The  amount  of  dissemination 
varies  greatly:  in  some  cases  secondary  knots  occur  in 
almost  every  organ  ;  in  others  they  will  be  limited  to  the 
liver.  The  lymph-glands  adjacent  to  the  orbit  are  rarely 
infected.  It  is  curious  that  in  most  cases  death  results 
more  often  from  the  secondary  growths  involving  important 
organs  than  from  the  local  effects  of  the  primary  tumour. 
A  rare  complication  of  melanotic  tumours  is  pigmentation  of 
the  skin. 

The  duration  of  life  in  patients  with  intra-ocular  melano- 
mas rarely  extends  beyond  three  years.  A  careful  analysis 
of  a  large  number  of  cases  shows,  however,  that  in  many 
instances  life  may  be  indefinitely  prolonged  by  early  removal 
of  the  globe,  and  cases  are  known  in  which  patients  have 
been  reported  alive  and  well  five,  six,  eight,  nine,  sixteen  and 
eighteen  years  after  the  operation.  In  the  majority  of  cases 
that  recur  the  recurrence  takes  place  within  three  years  of 
the  operation.  Collins  and  Lawford,  calculating  cases  in 
which  recurrence  does  not  take  place  within  three  years  of 
operation  as  recoveries,  come  to  the  conclusion,  from  an 
analysis  of  seventy-nine  cases  of  which  they  were  able  to 
obtain  complete  records,  that  the  rate  of  recovery  is  25 
per  cent.,  but  they  point  out  that  patients  have  died 
from  recurrence  or  secondary  deposits  after  a  much  longer 
interval  than  three  years.  Dissemination  has  been  deferred 
for  so  long  a  period  as  eleven  years  after  excision  of  the 
eyeball  (Hutchinson). 

Melano-carcinomas. — Several  writers,  who  have  devoted 
attention  to  intra-ocular  tumours,  describe  some  of  the 
pigmented  tumours  as  carcinomas,  using  the  term  in  the 
definite  sense  in  which  it  is  employed  in  this  work.  Much 
new  light  has  been  thrown  on  this  question  by  the  interesting 
investigations  of  Treacher  Collins.  This  ophthalmologist  has 
demonstrated  the  existence  in  the  ciliary  body,  in  the  space 


118 


GONNEGTIVE-TISSUJS    TVMOtJRS 


extending  from  the  root  of  the  iris  to  the  ora  serrata,  of  a 
number  of  small  tubular  processes  composed  of  epithelial 
cells  with  the  free  ends  projectinf^  towards  the  ciliary 
muscle  (Fig.  66).  Collins  succeeded  in  demonstrating 
the  existence  of  these  processes  by  bleaching  the  cells. 
The  ciliary  glands  are  interesting  in  connexion  with 
melano-carcinoma,  for  Collins  discovered  among  the  intra- 
ocular tumours  preserved  in  the  museum  of  the  Moorfields 
Hospital  two  examples  from  the  ciliary  body  which  were 
epithelial   in   character.      In    examining    them   he   adopted 


Fig.  66.— Bleached  section  of  the  glands  of  the  ciliary  body.    {After  Collins.) 


the  bleaching  method,  to  which  reference  has  already 
been  made. 

We  must  agree  with  his  observation,  that  melano- 
carcinoma  is  unknown  except  as  a  primary  tumour  arising 
in  the  ciliary  body. 

Melanomas  are  of  fairly  common  occurrence  in  horses  : 
the  regions  most  affected  are  the  tail  and  the  parts  about 
the  anus,  where  they  form  large  mushroom-like  excres- 
cences, with  little  disposition  to  ulcerate.  The  tumours  in 
some  cases  attain  large  proportions,  and  have  been  known 
to  weigh  forty,  fifty,  and  even  sixty  pounds.  When  a  large 
tnmour  grows  from  a  horse's  tail  it  becomes  a  great  encum- 
brance, which  the  veterinarian  removes  by  amputation.     It 


GANGEBODEBMS  119 

occasionally  happens  that  in  the  operation  a  portion  of  the 
tumour  is  left  behind,  and  its  cut  surface  heals  like  other 
tissues.  These  pigmented  tumours  are  very  prone  to  dis- 
seminate, and  secondary  nodules  occur  in  almost  all  the 
viscera ;  in  spite  of  this,  melano-sarcoma  does  not  appear  to 
be  such  a  malignant  affection  in  horses  as  in  men. 

Although  most  common  in  grey,  it  also  occurs  in  white, 
and  occasionally  in  black  horses ;  and  it  certainly  occurs  in 
cows.  Next  to  the  anus  and  tail,  the  udder  is  the  most 
frequent  seat  of  the  primary  tumour,  and  it  may  spring  up  in 
the  subcutaneous  connective  tissue  in  any  part  of  the  trunk. 
Horses  may  be  attacked  at  any  age  from  four  years  upwards. 
In  structure,  melano-sarcoma  of  the  horse  resembles  a  hard 
uterine  fibroid  rather  than  a  sarcoma.  In  these  aninials 
melano-sarcoma  of  the  uveal  tract  is  very  rare. 

Sarcoma  idiopathicum  multiplex  hsemorrhagicum. — ■ 
This  rare  disease,  described  by  Kaposi,  has  been  most  fre- 
quently seen  in  Polish  Jews.  It  attacks  the  feet  and  hands 
and  gradually  extends  up  the  limbs.  The  skin  involved  in 
this  disease  in  the  most  typical  cases  is  bluish-red,  and  the 
nodules,  which  tend  to  become  confluent,  vary  in  size  from 
a  split  pea  to  a  hazel-nut.  The  tumour-nodules  are  very 
vascular,  and  on  microscopic  examination  resemble  spindle- 
celled  sarcomas.  The  coloration  is  due  to  blood,  so  that 
this  disease  is  quite  different  from  melanoma. 

De  Morgan  spots  (canceroderms). — ^It  is  not  uncommon 
to  find  on  the  skin,  especially  of  the  abdomen  and  chest 
of  patients  debilitated  by  cancer,  numbers  of  small  raised  red 
spots  looking  like  na3vi.  These  are  often  called  "  De  Morgan 
spots,"  after  Campbell  De  Morgan  (1872),  who  regarded 
them  as  almost  pathognomonic  of  cancer:  they  are  patches 
of  pigment,  and  not  nsevi. 

These  spots  have  been  carefully  studied  by  Brand  and 
Leser.  Their  conclusions  are  of  interest,  for  they  point  out 
that  the  J  spots  do  not  appear  in  healthy  subjects,  or  in 
persons  suffering  from  other  diseases  in  early  or  middle  life, 
and  never  even  in  old  age  in  large  numbers.  When  these 
spots  are  plentiful  there  is  every  reason  to  suspect  cancer. 
I  have  made  careful  observations  of  them  for  twenty-five 
years  in  regard  to  their   association  with   cancer,  and    find 


120  CONNECTIVE-TISSUE   TUMOURS 

that  they  are  as  common  in  the  non- cancerous  as  in  those 
afflicted  with  this  disease. 

Ochronosis  and  alkaptonuria. — For  many  years  after 
Tirchow,  in  1866,  drew  attention  to  the  peculiar  discolora- 
tion of  the  cartilaginous  tissues  of  the  body  under  the 
designation  ochronosis,  it  may  be  said  to  have  remained  a 
pathologic  curiosity,  until  Albrecht  (1902)  drew  attention  to 
the  occasional  relationship  which  exists  between  this  disease 
and  the  curious  and  rare  condition  of  the  urine  known  as 
alkaptonuria. 

The  condition  termed  ochronosis  scarcely  amounts  to  a 
disease,  as  it  in  no  way  shortens  life,  and  in  the  early  cases  the 
changes,  which  consist  of  blackening  of  the  costal  cartilages, 
the  gristly  parts  of  the  pinna  and  sclerotic,  were  only 
discovered  at  a  post-mortem  examination.  In  cases  sub- 
sequently reported,  such  fibrous  structures  as  the  inter- 
vertebral discs  and  the  chordae  tendineee  have  been  found 
discoloured,  and  in  a  remarkable  case,  recorded  by  Pope,  the 
rib  cartilages  were  blue-black,  the  ears  w^ere  blue,  there 
were  black  patches  on  the  inside  of  tho  ^lips,  and  the  skin  of 
the  face  had  broAvn  patches  not  unlike  the  pigmentation  of 
Addison's  disease.  On  microscopic  examination  of  a  patch  of 
pigmented  skin  from  a  patient  with  ochronosis,  the  pigment 
particles  were  found  in  the  elastic  tissue  of  the  skin,  but  not 
in  the  rete  Malpighii.  Osier  has  reported  a  case  in  which 
there  was  skin  pigmentation. 

Alkaptonuria  has  been  particularly  investigated  by 
Garrod;  its  essential  features  are  as  follows:  The  urine, 
though  of  normal  appearance  when  passed,  acquires  a  deep 
brown  colour  and  ultimately  becomes  black  on  exposure  to 
the  air.  The  brown  colour  is  intensified  by  alkalies.  The 
urine  reduces  Fehling's  solution  with  the  aid  of  heat,  and 
actively  reduces  ammoniacal  silver  nitrate  solution  in  the 
cold.  Fabrics  moistened  with  alkaptonuric  urine  became 
deeply  stained  on  exposure  to  the  air. 

This  anomaly  often  dates  from  infancy,  and,  in  one  case 
at  least,  staining  of  the  napkins  by  the  urine  was  noticed 
the  day  after  birth, 

Garrod,  m  his  classical  analysis  of  this  disorder,  states 
that    "  homogentisinic    acid    is    a    constant    constituent    of 


XANTHOMA  l2l 

alkapton  urines,  and  plays  the  chief  part  in  the  production 
of  alkaptonuria." 

In  regard  to  the  relationship  between  ochronosis  and 
alkaptonuria,  Garrod  writes  :  "  There  are  very  strong  grounds 
for  believing  that  in  later  life  alkaptonuric  subjects  tend  to 
develop  the  characteristic  pigmentation  of  cartilages ;  in  other 
words,  that  alkaptonuria  is  a  cause,  but  not  the  only  cause 
of  ochronosis." 

Chloroma  (green  tumours). — This  is  an  exceedingly  rare 
disease  in  which  sarcoma-like  masses  form  on  the  bones  of 
the  skull  and  face,  especially  in  the  neighbourhood  of  the 
orbits,  and  infect  other  organs  secondarily.  After  death  the 
colour  of  the  tumour-like  masses  is  grass-green.  The  nature 
of  the  disease  is  obscure :  some  writers  regard  it  as  a  form 
of  leukaemia.  It  has  been  carefully  studied  by  Melville  Dunlop. 
Xanthoma. — This,  with  its  many  synonyms,  is  a  curious, 
harmless  pigment  disease,  especially  liable  to  appear  in 
the  skin  of  the  eyelids  near  the  inner  canthus.  Histologic- 
ally it  consists  of  a  fibrous  and  fatty  tissue  containing  yellow 
pigment  and  connected  with  the  corium.  In  the  eyelids  the 
disease  is  usually  symmetrical  and  occasionally  congenital. 
These  early  cases  have  led  some  observers  to  regard  the 
disease  as  allied  to  nesvi. 

Xanthoma  may  occur  on  any  part  of  the  skin  (A''. 
viultiplex),  and  in  many  instances  is  associated  with  jaundice 
and  disturbance  of  the  liver. 

The  orange-coloured  pigment  is  interesting  from  a  phy- 
siological point  of  view  in  connexion  with  the  oil-gland 
of  the  rhinoceros  hornbill  (Bucorvus  abyssinicus).  In  this 
bird  the  gland  secretes  an  orange-coloured  material  with 
which  it  preens  its  feathers. 

The  only  normally  pigmented  tissue  found  in  the  human 
body  resembling  the  yellow  and  orange  of  xanthoma  patches 
is  the  lutein  tissue  in  the  corpus  luteum  and  the  Avails  of 
lutein  cysts  arising  therefrom. 

Brand,  "  Canceroderms."— ^/-i^.  Med.  Journ.,  1902,  ii.  494,  730. 

Collins,  E.  Treacher,  "  Cysts  of  the  Glands  of  the  Ciliary  Body.    Researches  on 
the  Anatomy  and  Physiology  of  the  Eye,"  London,  1900. 

Collins  and  Lawford,  "  Notes  on  Three  Hundred  Cases  of  Sarcoma  of  the  Uveal 
Tract." — Roy.  Lond.  Ojjhthal.  Hosp.  Repts.,  1891,  xiii.  104. 


122  CONNECTIVE-TISSUE  TUMOURS 

Dunlop,  "  Chloroma." — Brit.  Med.  Journ.,  1902,  i.  453. 

Fischer,  G.,    "  Melanosarkom  der  Penis," — BeuUclie  Zeitschr.  f.   Cldr.,  1887, 
XXV.  313. 

Fox,  Wilfred  S-,  "  Researches  into  the  Origin  and  Structure  of  Moles,  and  their 
Relation  to  Malignancy." — Brit.  Journ.  of  Berm.,  Jan.  1906. 

Garrod,  "A  Contribution  to  the  Study  of  Alkaptonuria." — Med.-Chir.  Trans., 
1899,  Ixxxii.  867. 

Holland,    E.,    "  Malignant  Melanoma  of  the  Vulva." — Journ.  of   Oistet.  and 
Gyn.,  1908,  xiv.  809. 

Hutchinson,  J.,  jun.,   '•  Melanotic  Sarcoma  of  the  Skin." — Trans.  Path.  Soc, 
1898,xliv.  148. 

Kaposi,  "  Sarcoma  idiopathicum  multiplex  hfemorrhagicum." — Bandatlas  der 
HautliranTilieitcn,  Leipzig,  1900,  Tafeln  301,  302. 

Payr,  E.,  "  Melanom  der  'Penis.'"— Be^itscJie'Zeitschr.f.  Chir.,  1899,  Bd.  liii.  221, 

Pope  and  Gaxrod,  "  A  Case  of  Ochronosis,  with  table  of  eleven  cases  previously 
reported." — Lancet,  1906,  i.  24. 

Treves,  Sir  Frederick,   "Melanoma  of   the  Hard  Palate." — Trans.  Path.  Soc. 
Land.,  xxxviii,  350, 


CHAPTER  Xr 
MOLES 

Moles  are  pigmented  and,  usually,  hairy  patches  of  skin. 
These  patches  are  congenital,  and  vary  greatly  in  size ;  many 
are  no  bigger  than  split  peas,  others  cover  an  extensive 
area  on  the  face,  trunk,  or  limbs. 

The  common  variety  consists  of  a  slightly  raised  brown 
patch ;  it  is  sometimes  quite  black,  and  is,  as  a  rule,  covered 
abundantly  with  hair,  which  is  commonly  short  (ncevus 
pilosus)  ;  occasionally  it  is  as  long  as  that  naturally  found 
upon  the  scalp.  The  hairs  are  furnished  with  sebaceous 
glands,  and  sweat-glands  are  often  present.  The  amount  of 
pigment  varies  ;  occasionally  it  is  so  abundant  as  to  produce 
an  inky  blackness.  Some  black  blemishes  are  glabrous 
(ncevus  spilosus).  Moles  are  very  vascular,  but  the  most 
striking  feature  of  their  histology  is  the  fact  that  the  tissue 
immediately  underlying  them  is  arranged  in  alveoli.  The 
most  important  change  to  which  they  are  liable  is  to  become 
later  in  life  the  starting-point  of  melanomas,  some  of  which 
are  very  infective,  and  quickly  destroy  life. 

When  very  large  moles  occur  on  the  trunk  the  hairy 
part  is  sometimes  very  sensitive,  almost  hypersesthetic.  In 
large  moles,  pendulous  skin-folds  are  sometimes  present  ; 
these  folds  are  large  in  the  young,  but,  as  a  rule,  they  shrink 
and  become  quite  small  in  the  adult.  As  many  as  fifty  moles 
may  be  present  on  one  individual.  When  a  mole  is  extensive, 
and  occurs  in  an  exposed  situation,  it  is  a  serious  disfigure- 
ment. The  relation  of  moles  and  plexiform  neuromas  is 
described  on  p.  140. 

Small  hairy  moles  do  not,  as  a  rule,  cause  much  in- 
convenience even  when  they  occur  on  the  face,  in  which 
situation  they  are  known  as  "  beauty  spots."  A  small  hairy 
mole  on  a  fair  cheek  is  regarded  often  as  an  additional  charm 

123 


124   .  CONNECTIVE- f ISSUE  TUMOUR^ 

rather  than  a  disfigurement,  if  we  can  trust  the  taste  of 
story-tellers,  poets,  and  playwrights. 

Cervantes,  describing  the  comic  achievements  of  Don 
Quixote,  makes  the  beautiful  Dorothea  describe  her  cham- 
pion as  having  on  his  right  side,  under  the  left  shoulder, 
or  somewhere  thereabouts,  a  tawny  mole  overgrown  with  a 
tuft  of  hair  not  unlike  that  of  a  horse's  mane.  (Motteux's 
translation.  Chap,  xxx.) 

In  the  "  Arabian  Nights  "  the  allusions  are  many ;  thus  the 
youth  in  the  Eldest  Lady's  Tale  saj'^s :  "  Persian  poets  have  a 
thousand  conceits  in  praise  of  the  mole."  Some  of  these 
allusions  are  certainly  exquisite.     Here  is  an  example : 

"  A  nut-brown  raole  sits  throned  upon  a  cheek 
Of  rosiest  red  beneath  an  eye  of  jet, 

English  writers  often  refer  to  moles.  Marlowe,  in  his 
powerful  tragedy  Dr.  Faustus,  when  he  causes  Alexander  and 
his  paramour  (Act  iv.,  sc.  1)  to  appear  before  Charles,  Emperor 
of  Germany,  makes  the  Emperor  say  : 

"  I  have  heard  it  said 
That  this  fair  lady,  when  she  lived  on  earth, 
Had  on  her  neck  a  little  wart  or  mole.", 

There  are  numerous  references  to  moles  scattered  in 
Shakespeare's  plays.  All  who  have  read  Cymbeline  will 
remember  the  cunning  use  lachimo  makes  of  the  fact  that 
Imogen  had 

"  On  her  left  breast  , 

A  mole  cinque-spotted,  like  the  crimson  drops 
I'  the  bottom  of  a  cowslip." 

Cymbeline,  when  his  lost  sons,  Guiderius  and  Arviragus,  are 
presented  to  him  in  his  tent,  says  : 

"  Guiderius  had 
Upon  his  neck  a  mole,  a  sanguine  star ; 
It  was  a  mark  of  wonder." 

To  which  Belarius  replies : 

"  This  is  he. 
Who  hath  upon  him  still  that  natural  stamp 
It  was  wise  Nature's  end  in  the  donation 
To  be  his  evidence  now." 


MOLES 


125 


In  the  Comedy  of  Errors,  Dromio  of  Syracuse,  in  his 
comic  account  of  the  kitchen  wench,  tells  his  master  that 
she  knew  what  private  marks  he  had  about  him,  such  as 
"  the  mole  in  my  neck,  the  great  wart  on  my  left  arm," 
etc.     (Act  iii.,  sc.  2). 

The  occurrence  of  moles  and  other  varieties  of  mother- 


rig.  67. — An  extensive  hairy  mole. 
(From  a  jncture  in  the  Museum  of  the  iliddlesex  Hospital.) 

marks  has  always  been  a  subject  of  great  speculation  among 
matrons  and  the  superstitious  of  all  countries  and  all  times. 
Peculiarly  marked  bull  calves  (apis  bulls)  were  particularly 
venerated  by  the  priests  at  Memphis,  and  when  these  bulls 
died  they  were  accorded  remarkable  sepulchral  rites. 

Moles  are  more  particularl}'^  related  to  the  "  longings  "  of 
pregnant  women,  who  believe  that  if  these  are  not  appeased 
the   child   will  appear  with   the   wished-for    article,  usually 


126 


CONNECTIVE-TISSUE   TUMOURS 


flowers  or  fruit,  marked  on  its  skin.  Though  these  matters 
receive  no  support  from  the  scientific  investigator,  there 
is  no  belief  more  deeply  rooted  in  the  minds  of  matrons, 
3"oung  or  old.  The  tradition  comes  to  us  from  remote  anti- 
quity, and  the  way  in  which  Jacob  turned  it  to  advantage  is 
well  set  forth  in  his  crafty  management  of  Laban's  flock 
(Genesis  xxx.  37). 


Fig.  68. — Extensive  hairy  mole  upon  the  face  of  a  boy  a  year  old. 


The  case  of  Esau  who  "  came  out  red  all  over  like  an  hairy 
garment"  (Genesis  xxv.  25),  which  curiously  fascinates  biblical 
commentators  and  matrons,  had  a  parallel  in  a  girl  born  at 
Pisa,  hairy  all  over.  In  this  instance,  the  mother  attributed 
it  to  the  fact  that  during  her  pregnancy  she  had  gazed  at  a 
picture  of  John  the  Baptist.  This  is  a  good  example  of  the 
circumstantial  and  plausible  way  women  endeavour  to  account 
for  these  things.     The  belief  even  survives  the  ridicule   of 


CONJUNCTIVAL    MOLES  127 

Charles  Dickens,  who  represents  Mrs.  Gamp  telling  about  a 
man  six-foot-three  "  marked  with  a  mad  bull  in  Wellinofton 
boots  upon  the  left  arm,"  because  his  mother  took  refuge  in  a 
shoemaker's  shop  when  frightened  by  a  mad  bull  during  her 
pregnancy  ("  Martin  Chuzzlewit,"  Chap.  46). 

Hairy  patches  on  the  conjunctiva  (conjunctival  moles). 
— The  mucous  membrane  (conjunctiva)  on  the  ocular  surface 
of  the  eyelids  and  adjacent  portions  of  the  eyeball  occasionally 
presents  a  patch  of  skin  which  in  appearance  and  structure 
resembles  a  hairy  mole.  Such  a  patch  is  called  a  dermoid 
pterygium. 

These  dermoid  patches  occur  most  frequently  at  the 
margins  of  the  cornea,  and  usually  in  the  line  of  the  palpe- 
bral fissure — that  is,  directly  in  the  equator  of  the  cornea  ;  but 
they  are  by  no  means  confined  to  these  situations.  Usually 
they  are  limited  to  the  conjunctiva  covering  the  sclerotic,  or 
trespass  but  little  on  the  cornea.  Sometimes,  however,  they 
involve  a  considerable  extent  of  the  corneal  surface  (Fig. 
69).  Wardrop  described  one  in  a  man  50  years  of  age  ; 
it  was  congenital.  Twelve  long  hairs  grew  from  its  middle, 
passed  between  the  eyelids,  and  hung  over  the  cheek. 
These  hairs  did  not  appear  until  the  sixteenth  year,  at 
which  time  the  beard   began  to  grow. 

Occasionally  a  mole  will  be  found  on  each  side  of  the 
cornea  in  the  line  of  the  palpebral  fissure.  A  rare  variety 
is  limited  to  the  caruncle  :  this  is  simply  an  excessive  de- 
velopment of  the  delicate  hairs  that  normally  beset  the 
caruncle  (Fig.  70). 

These  moles  are  occasionally  associated  with  malforma- 
tions of  the  eyelids,  especially  the  one  known  as  coloboma 
of  the  upper  eyelid.  When  this  association  occurs,  the 
defect  in  the  lid  corresponds  to  the  cutaneous  patch  on  the 
conjunctiva.  This  combination  is  of  some  importance,  as  it 
is  used  as  evidence  in  support  of  an  explanation  that  has 
been  put  forward  in  regard  to  such  hairy  patches,  based 
upon  the  development  of  the  eyelids. 

In  the  embryo  the  tissue  covering  the  outer  surface  of 
the  eyeball,  which  ultimately  becomes  the  conjunctiva,  is 
directly  continuous  and  in  structure  identical  with  the 
skin   at   the   margin    of    the   orbit.     Very    early,   cutaneous 


128 


CONNECTIVE-TISSUE   TUMOURS 


folds  arise  and  gradually  grow  over  the  surface  of  the  eyeball, 
and  come  into  apposition  at  a  spot  corresponding  to  the 
future  palpebral  fissure.  These  folds  ultimately  become  the 
eyelids.     The  surface  of  each  fold,  which  is  continuous  with 


'^'^'MMim^ 


Fig.  6P. — Dermoid  pterygium — common  varietj'. 

the  covering  of  the  eyeball,  becomes  converted  into  mucous 
membrane,  termed  conjunctiva.  In  every  normal  eye  the 
conjunctiva  bears  evidence  of  its  transformation  from 
skin,  inasmuch  as  the  caruncle  at  its  inner  angle  is  iur- 
nished  with  delicate  hairs.  It  is  reasonable  to  suppose  that, 
as  the  occlusion  of  the  proper  covering  of  the  eyeball 
by  the  eyelids  is  the  cause  of  the  conversion  of  the  con- 
junctiva  into  mucous  membrane,  if  from  any  cause  a  part, 


Fig.  70. — Excessive  growth  of  hair  on  the  caruncle,  associated  with  an  eccentric 
pupil.     {After  Semours.) 

or  even  the  Avhole  of  it,  were  left  uncovered,  the  exposed 
part  would  persist  as  skin.  This  is  precisely  what  occurs. 
When  the  eyelid  is  in  the  condition  of  coloboma — a  defect 
due,  in  all  probability,  to  the  imperfect  union  of  the  em- 
bryonic eyelid  to  the  skin  covering  the  fronto-nasal  plate — 


DERMOID   PTERYGIUM 


129 


a  piece  of  conjunctiva  persists  as  skin,  and  forms  a  mole 
occupying  the  gap  in  the  Hd.  Moles  occur  on  the  con- 
junctiva unassociated  with  coloboma,  but  in  nearly  every 
instance  they  are  situated  on  the  cornea  in  the  line  of  the 
palpebral  fissure.  This  circumstance  would  indicate  that 
during  development  the  conjunctiva  was  imperfectly  covered 
by   the   developing  lids.      In   a   few  very  exceptional   cases 


Fig.  71. — Dermoid  pterygium  in  a  sheep. 

the  eyes  have  been  found  completely  covered  with  skin 
without  any  traces  of  eyelids.  Such  a  condition  is  known 
as  cryptophthalmos,  and  the  explanation  offered  concerning 
it  is,  that  in  these  cases  the  eyelids  have  failed  to  appear, 
and  in  consequence  the  conjunctiva  has  jjersisted  as  skin. 

Conjunctival  moles  have  been  observed  in  horses,  sheep, 
oxen,  and  dogs,  and  are  furnished  with  hair  or  wool, 
according  to  the  nature  of  the  tegumentary  covering  of 
the  mammal  in  which  they  occur. 


CHAPTER    XII 

NEUROMAS  AND  ALLIED  CONDITIONS  OF  THE 
NERVOUS  SYSTEM 

Neuroma. — This  may  be  defined  as  a  tumour  growing 
from,  and  in  structure  resemblino-    the  sheath   of  a  nerve. 

The  term  neuromas  is  frequently  used,  especially  in 
clinical  work,  as  signifying  tumours  on  nerves,  but  as  such 
tumours  are  sometimes  composed  of  fibrous,  fatt}^  or  even 
sarcomatous  tissue,  it  would  be  better  to  speak  of  them 
as  lipomas  of  nerves,   sarcomas  of  nerves,   and   so   on. 

The  tumours  which  most  strictly  correspond  to  my 
definition  are  those  known  as  neuro-fibromas,  and  it  will 
be  convenient  to  include  the  curious  nodule  known  as  the 
"  painful  subcutaneous  tubercle." 

A  neuro-fibroma  is  usually  fusiform,  and  grows  from 
the  side  of  a  nerve;  when  large,  it  may  spread  out  the 
fasciculi  of  the  nerve ;  exceptionally  the  nerve-fibres  will 
traverse  the  tumour.  The  long  axis  of  the  neuroma 
coincides  with  that  of  the  nerve  from  which  it  grows. 

In  size  neuro-fibromas  vary  greatly :  some  are  no 
larger  than  lentils,  others  may  be  as  big  as  eggs ;  larger 
specimens  are  very  exceptional.  They  occur  on  the  cranial 
as  well  as  on  the  spinal  nerves,  and  form  on  their  roots 
trunks,  branches,  or  the  terminal  twigs.  Neuro-fibromas 
form  smooth  swellings,  which  are  mobile,  and  when  situated 
in  the  subcutaneous  tissue  glide  easily  under  the  skin ; 
they  are  encapsuled,  may  be  easily  enucleated,  and  are 
extremely  liable  to  become  myxomatous,  and  in  large 
specimens  this  change  leads  to  the  formation  of  cavities 
in  the  tumours.  These  changes  account  for  the  various 
names  applied  to  them,  such  as  myxoma,  myxo-fibroma, 
myxo-sarcoma,  and  the  like. 

Painful  subcutaneous  tubercle. — This  term  was  applied 

130 


NEUROMAS  131 

by  Wood  in  1812  to  a  small  discrete  nodule  which  forms 
in  the  subcutaneous  tissue.  It  is  usually  of  the  "size  and 
form  of  a  flattened  garden  pea,"  but  it  very  rarely  exceeds 
the  size  of  a  coffee-bean.  When  examined  by  the  finger 
it  feels  like  a  small  shotty  body  slipping  about  imme- 
diately beneath  the  skin.  Structurally  the  "  tubercle "  con- 
sists of  fibrous  tissue  very  like  that  which  constitutes  the 
bulk  of  the  nodules  in  molluscum  fibrosum ;  it  is  rare 
that  a  nerve-fibril  can  be  traced   to  it. 

The  interest  of  these  bodies  is  due  to  the  "  very 
severe  and  excruciating  pain"  associated  with  them.  The 
pain  is  paroxysmal,  and  usually  increases  in  severity  and 
in  frequency  according  to  the  length  of  time  the  disease 
has  existed.  If  the  "  tubercle  " — for  it  is  usually  solitary — 
is  struck,  or  even  touched,  acute  pain  is   produced. 

They  occur  much  more  frequently  in  women  than  in 
men,  and  are  commonly  met  with  in  early  adult  life;  and 
though  a  "  tubercle "  may  form  on  any  part  of  the  body, 
it  shows  marked  preference  for  the  lower  limb.  Excision 
of  the  little  body  at  once,  and  permanently,  arrests  the 
pain. 

Ganglionic  neuroma. — This  is  a  tumour  composed  of 
nerve-cells,  nerve-fibres,  and  neuroglia.  They  are  extremely 
rare  tumours.  Klebs  described  a  tumour  of  this  kind 
which  grew  from  the  floor  of  the  fourth  ventricle  near  the 
calamus  scriptorius.  The  tumour  was  nearly  as  large  as 
a  walnut.  It  has  been  thought  that  some  tumours 
described  as  gliomas  may  have  been  ganglionic  neuro- 
mas ;  on  the  other  hand,  however  carefully  the  histologic 
features  of  these  tumours  have  been  described,  there  has 
always  been  a  doubt  lest  normal  brain-tissue  became 
included  in  the  tumour.  However,  this  cloud  has  been 
dispelled  by  the  observation  that  tumours  containing 
ganglionic  tissues  occur  in  connexion  with  the  great 
cords  of  the  sympathetic  system  as  well  as  in  the  sub- 
cutaneous tisue. 

In  one  of  the  most  remarkable  cases,  recorded  by 
Knauss,  a  girl  8  years  old  had  sixty-three  tumours  in  the 
subcutaneous  tissue  of  the  trunk  and  thighs  (Fig.  72); 
they   varied  in   size   from    a    pea   to   an  orange,  were  firm 


132 


CONNECTIVE-TISSUE   TUMOUSS 


and  elastic,  and  not  painful.     Microscopically  these  tumours 
were    found    to     be    composed    of    ganglionic    nerve-cells, 


Fig.  72. — Girl  8  years  of  age  with  sixty-three  ganglionic  neiiromas  in   the 
subcutaneous  tissue   of  the  trunk  and  thigh.     {Knauss.) 

medullated  and  non-medullated  nerve-fibres.   Knauss  believed 
that   the    tumours   were   derived  from    the   minute   ganglia 


QANGLIONIG  NEUROMAS 


133 


on  the  finest  terminal  fibres  of  the  sympathetic  system  which 
accompany  the  blood-  and  lymph-vessels.    Knauss's  description 


Fig.  73. — Multiple  inoUuscum  fibrosum. 

of  the  microscopic  characters  of  the  tumours,  which  clinically 
resembled  lipomas,  is  accompanied  by  careful  drawings. 


13i 


G ONNEG  TIVE-  TISS  UE   TUMO  UBS 


NEURO-FIBROMATOSIS 
Under    this    heading    it   is   now   necessary   to    describe 
several    affections  which   were   formerly  regarded    as   being 
quite   distinct.     These   are    multiple   neuromas,   molluscum 


Fig.  74. — Native  of  Sierra  Leone  aged  50  years  with  molluscum  fibrosum. 
The  tumours,  which  were  congenital,  varied  in  size  from  a  pepjjercorn 
to  a  billiard-ball.     {Lamjrrey.) 

fibrosum,  plexiform  neuromas,  sarcomas  of  nerves,  and  glioma. 
It  will  be  useful  to  state  a  few  facts  concerning  each  of  these 
conditions  before  describing  their  intimate  relationship. 

It    has    long    been    known    that    neuromas    sometimes 


NE  UBO-FIBBOMATOSIS 


13.: 


occur  on  nerves  in  extraordinary  numbers.  The  remark- 
able case  of  Micliael  Lawlor,  described  in  Smith's  classical 
monograph,  was  in  all  probability  an  example  of  this  com- 
bination. It  was  estimated  that  this  man  had  at  least 
2,000  tumours.  There  were  450  tumours  counted  on  the 
nerves  of  the  right  lower  limb,  and  300  on  the  left.  There 
were  200  tumours  on  the  right  and  100  on  the  left  upper 
limb.      The     pneumogastric     nerves     and     their     branches 


Fig.  75. — Native  of  Bengal  with  molluscum  fibrosum  of  the  arm :  there  were  also 
discrete  nodules  on  other  jparts  of  the  body.  The  man  belonged  to  the  cow- 
keeper  caste.     {From  a photofirajih  sent  hy  Dr.  Maddox,  Bengal.) 

possessed  60  tumours,  some  of  large  size.  The  remainder 
were  on  the  trunk. 

Several  cases  of  this  kind  have  been  carefully  described, 
but  probably  in  no  individual  has  a  greater  number  of 
nodules  been  detected. 

In  1882  Professor  von  Recklinghausen  published  an  im- 
portant monograph,  in  which  he  demonstrated  not  only  that 
multiple  neuromas  were  sometimes  associated  with  molluscum 
fibrosum,  but  that  the  two  conditions  were  closely  related,  and 


136 


CONNECTIVE -TISSUE   TUMOURS 


he  urged  that  the  moUuscum  bodies  of  the  skin  are  formed 
on  the  cutaneous  nerves,  and  are  as  truly  neuromas  as  the 
tumours  on  the  epineurium  of  the  larger  nerves. 

In  typical  cases  of  moUuscum  fibrosum  the  skin  of  the 
trunk  and  limbs  presents  numerous  small  tumours,  consisting 


Fig 


-Multiple  moUuscum  nodules  on  the  scalp,  nose,  and  fingers.     The  nodules 
on  the  fingers  were  ia  the  course  of  the  digital  nerves. 


mainly  of  fibrous  tissue  springing  from  the  subcutaneous 
connective  tissue.  These  tumours  are  of  various  sizes,  some 
being  no  larger  than  a  pin's  head,  whilst  many  are  as  big  as  a 
filbert,  and  a  few  even  larger.  The  majority  are  about  the 
size  of  a  small  pea.  Many  are  sessile,  and  others  are  distinctly 
pedunculated,  but  all  are  covered  with  skin.     These  tumours 


MOLLTTSGUM  FiBROSTJM 


137 


are  mobile,  soft  to  the  touch,  and  of  the  consistence  of  firm 
fat.  Sometimes  the  disease  affects  a  broad  area  of  skin  on  the 
head,  trunk,  or  hmbs,  causing  it  to  hang  in  pendulous  folds 


Fig.  77. — Molluscum  fibrosum  of  the  vulva  in  a  negress.  The  tumour  was  removed  : 
it  weighed  75  lbs.  The  tumour  had  beau  growing  ten  years  :  after  its  removal 
the  patient  conceived,  and  was  delivered  of  twins  in  the  bush.  She  died  of 
puerperal  fever. 

(Figs.    74,   75).     Exceptionally   the   pendulous   and   nodular 
lesions  occur  in  the  same  patient  (Fig.  74). 

In  its  mildest  form  molluscum  fibrosum  appears  as  a 
single  pedunculated  tumour,  a  frequent  situation  being  the 
labium  majus  (Fig.  77). 


138  GONNEGTIVE-TISSVE   TUMOURS 

The  structure  of  these  soHtary  tumours  is  the  same  as  the 
nodules  in  the  muhiple  forms  and  the  pendulous  skin-folds. 
An  unusual  situation  is  the  mammary  areola  (Fig.  78)  or  the 
nipple.  When  these  nodules  grow  from  the  nose  they  are 
apt  to  be  confounded  with  the  condition  commonly  but 
erroneously  called  "lipoma  nasi." 

Concerning  the  cause  of  molluscum  fibrosum,  nothing  is 
known.     The  disease  is  not  confined  to  any  climate  or  race, 


/,  V  /W^.Jc 


Fig.  78. — Pedunculated  molluscum  fibrosum  from  the  nipple  of  a  woman. 
[Museum,  Middlesex  Hospital.') 

for  it  has  been  observed  in  North  America,  the  British  Isles, 
India,  Germany,  and  the  West  Coast  of  Africa. 

Under  the  term  pachydermatocele,  Mott  (1854)  described 
and  figured  several  examples  of  the  pendulous  form  of  mol- 
luscum fibrosum  which  were  successfully  submitted  to  opera- 
tion, and  the  early  volumes  of  the  Transactions  of  the 
Pathological  Society,  London,  contain  descriptions  and  figures 
of  this  disease  under  a  variety  of  names.  The  frontispiiece  to 
Virchow's  "Die  Krankhaften  Geschwtilste"  is  a  representation 
of  a  woman  with  pendulous  folds  and  a  multitude  of 
cutaneous  nodules,  under  the  title  "  fibrosum  molluscum 
multiplex."  The  disease  appears  to  be  equally  common 
in  men  and  in  women. 


SARCOMA   OF  NERVES  139 

An  important  feature  connected  with  the  typical  general- 
ized neuro-fibromatosis  is  the  liability  of  the  patients  to 
sarcoma ;  this  may  develop  primarily,  or  arise  as  a  malignant 
change  in  a  molluscum  nodide  which  has  existed  very 
many  years.  Sarcomas  of  this  kind  do  not,  as  a  rule, 
disseminate. 

In  the  generalized  neuro-fibromatosis,  death  often  results 
from  gradual  exhaustion,  due  to  ulceration,  septic  changes,  or 
sloughing  of  the  pendulous  portions  of  the  skin.  In  many 
cases  some  intercurrent  malady  supervenes,  such  as  pneu- 
monia ;  in  patients  with  multiple  nodules  on  the  roots  of  the 
spinal  nerves,  one  of  them  may  so  enlarge  as  to  press  on 
the  cord  and  produce  fatal  paraplegia. 

In  regard  to  sarcoma  supervening  in  the  so-called  mollus- 
cum nodules,  it  is  necessary  to  remember  that  spindle-celled 
sarcomas  arise  primarily  in  nerve-trunks,  especially  in  the 
great  sciatic  and  its  branches,  quite  apart  from  the  existence 
of  neuro-fibromatosis,  localized  or  general.  A  sarcoma  of  a 
nerve  recurs  after  removal  or  amputation  of  the  limb,  but 
dissemination  is  not   frequent. 

Knauss,  "  Zur  Kentniss  der  achten  Neuroma." — Virchow's  Areli.,  cliii.  29. 

Mott,  Valentine,  "  Remarks  on  a  peculiar  form  of  Tumour  of  the  Skin  de- 
nominated 'Pachydermatocele';  illustrated  by  Cases." — Mecl.-CJdr. 
Trans.,  1854,  xxxvii.  155. 

Payne,  J.  F.,  "Multiple  Neuro-Fibromata  in  connection  with  Molluscum 
Fibrosura." — Trans.  Path.  Soc,  1887,  xxxviii.  69. 

von  Recklinghausen,  F.,  "  Ueber  die  multiplen  Fibroma  der  Haut,  und  ihre 
Beziehung  zu  den  multiplen  Neuromen." — Festschrift  zu  Rudolf  Virchow 
dargehraclit,  Berlin,  1882. 

Smith,  R.  W.,  "  Treatise  on  the  Pathology,  Diagnosis,  and  Treatment  of 
Neuroma,"  Dublin,  1849. 


CHAPTER   XIII 

NEUROMAS  AND  ALLIED  CONDITIONS  OF   THE 
NERVOUS  SYSTEM   (Continued) 

PLEXIFORM  NEUROMA. 

The  peculiar  condition  to  which  this  term  has  been  appHed 
is  essentially  a  fibromatosis  which  is  confined  to  a  par- 
ticular nerve  or  plexus  of  nerves.  Although  it  is  a  rare 
condition,  a  sufficient  number  of  cases  have  been  care- 
fully observed  and  recorded  to  enable  a  fairly  complete 
account  of  the  disease  to  be  written.  A  plexiform  neuroma, 
instead  of  forming  a  distinct  tumour  as  in  the  case  of  the 
solitary  neuro-fibroma,  appears  as  if  the  branches  of  a  nerve 
distributed  to  a  particular  area  of  the  skin  became  enlarged 
and  elongated.  The  overlying  skin  becomes  stretched,  thinned 
and  raised  over  the  thickened  nerves,  and  is  often  pigmented, 
the  usual  colour  being  brown,  like  that  characteristic  of  the 
hairy  mole.  Occasionally  the  skin  is  coarse  and  thick,  as  in 
the  case  of  a  moUuscum  nodule. 

The  tumour  feels  like  a  bag  containing  a  number  of 
tortuous,  irreo-ular,  vermiform  bodies,  soft  to  the  touch  and 
mobile.  These  bodies  vary  in  thicloiess  from  a  crow-quill  to 
that  of  the  thumb ;  manipulation  does  not  produce  pain, 
though  the  lumps  themselves  are  sensitive.  When  the  skin 
covering  the  tumour  is  reflected  these  elongated  bodies  will 
be  found  to  lie  in  the  direction  of  the  nerve  distributed  to  the 
part.  Thus,  on  the  back  they  will  run  in  a  transverse 
direction  (Fig.  79),  whereas  on  the  scalp  they  will  trend  to 
the  vertex,  and  so  on. 

When  these  thickened  nerves  are  divided  the  enlarge- 
ment will  be  seen  to  be  due  to  the  presence  of  a  gelatinous 
tissue,  and  the  appearance  of  the  cut  surface  reminds  one 
of  the  umbilical  cord.     Microscopic  examination  shows  that 

140 


PLEXIFOBM  NEUROMA  141 

tliis  thickening  is  due  to  overgrowth  of  the  connective  tissue 
of  the  nerve-sheath,  and  especially  that  part  of  it  known 
as  the  endoneurium — that  is,  the  delicate  connective  tissue 
between    the    individual    fibres    of    a    nerve-bundle.       The 


Fig.  79.  — Plexif orm  neuromafrom  the  back  of  a  youth  aged  19  years.     The  skiu 
was  the  seat  of  a  brown  haiiy  mole.     (Bmns.) 

enlargement  is  by  no  means  uniform,  so  that  the  so-called 
multiple  neuromas  are  really  due  to  local  irregularities 
in  a  diffuse  overgrowth  of  the  connective  tissue  of  the  nerve- 
sheath. 

Widely  different  opinions  are  held  by  equally  competent 
observers  in  regard   to  the  effects  of  these  changes   in  the 


142 


GONNEGTIVE-TISSUE    TUMOURS 


k 


'M 


my 


Fig.    80. — Plexiform   neuromas 
li^  affecting    the    roots    of    the 

chorda  equina   and   anterior 

crui'al  nerve. 


sheath  upon  the  axis-c^dinders  of 
the  nerves.  Some  maintain  that  de- 
generation occurs,  and  others  that 
they  are  not  affected.  This  ques- 
tion requires  careful  investigation. 
The  diffuse  character  of  the  en- 
largement in  plexiform  neuromas 
is  well  shown  in  a  remarkable 
specimen  preserved  in  the  Middle- 
sex Hospital  Museum  (Fig.  80). 
A  man  45  years  of  age  was 
admitted  into  the  hospital  with 
well-marked  paraplegia.  At  the 
post-mortem  examination  a  large 
number  of  small  nodules  was 
found  on  the  roots  of  the  nerves. 
Many  of  the  roots  were  so  beset 
with  them  as  to  resemble  strings 
of  beads.  In  the  cervical  region 
a  tumour  as  large  as  a  nut  had 
compressed  the  cord  and  produced 
paraplegia  (Fig.  81).  There  was  a 
neuroma  as  big  as  an  orange  on  the 
anterior  crural  nerve ;  there  were 
smaller  ex- 
amples on  the 
branches  of  the 
lumbar  plexus. 
When  these 
nerve-roots  are 
carefully  ex- 
amined they 
present  the  an- 
nulated  ap- 
pearance so 
characteristic  of 
the  root  of  the 
ipecacuanha 
plant,  and  it  is 
clearly  seen  that 


Fig.  81.— The  cervical 
segment  of  the  cord 
represented  in  the 
preceding  figure.  A 
nodule  on  one  of  the 
cervical  roots  com- 
pressed the  cord  and 
led  to  fatal  para- 
plegia. 


FLEXIFOBM  NEUROMA 


143 


the  nerve-roots  are  thickened  throughout,  and  that  the 
nodosities  are  local  exaggerations.  The  details  of  this  case 
were   recorded  by  Sibley  in  1866. 

Any  nerve,  cranial  or  spinal,  is  liable  to  this  disease, 
but  among  the  cranial  set  it  shows  marked  preference 
for  the  vagus  and  the  trigeminus.  It  may  affect  parts 
of  several  nerves,  or  be  limited  to  certain  branches  of  a 
single  nerve. 

The  roots  of  nerves  and  terminal  twigs  may  be  attacked 
as  well  as  their  trunks ;  and  the  branches  of  nerves  within  the 
muscles  may  display  nodosities.  The  sympathetic  nerves  do 
not  escape,  for  the  great  lateral  cords  as  well  as  the  visceral 
branches  may  be  nodular  with  this  disease,    (Alexis  Thomson.) 


Fig.  82. — Arm  in  which  the  musculo -spiral  nerve  and  its  branches  were  transformed 
into  a  plexiform  neui'oraa.     (After  Camphell  cle  More/an.) 

In  one  instance  the  nerves  involved  included  the  facial 
hypoglossal,  motor  portion  of  the  fifth  and  its  lingual  branch. 
The  enlargement  of  the  lingual  and  hypoglossal  nerves 
produced  macroglossia  in  a  child  aged  4  years,  for  which 
Abbott  excised  the  protruding  part  of  the  tongue.  Shattock 
investigated  the  diseased  organ,  and  the  outcome  was  an 
admirable  paper  of  great  value  and  interest. 

As  examples  of  the  disease  limited  to  part  of  a  nerve, 
reference  may  be  made  to  some  cases  in  which  the  ophthal- 
mic division  of  the  trigeminus  has  been  affected,  leadino-  to 
enlargement  of  the  upper  eyelid  and  proptosis,  which  neces- 
sitated excision  of  the  eyeball,  in  one  patient  with  fatal 
consequences  (Friedenwald,  Rockliffe  and  Parsons,  Treacher 
Collins  and  Batten). 


144 


CONNECTIVE-TISSUE   TUMOURS 


I  have  seen  a  plexiform  neuroma  strictly  limited  to  the 
great  occipital  nerve.  The  scalp  covering  the  affected  nerve 
was  transformed  into  a  brown  mole. 


Humerus. 


Musculo-spiral  ntrve. 

Brachio-radialis  muscle 
(supinator  longus). 


Neuroma. 


Neuroma  on  the  cuta- 
neous branches  of  the 
musculo -spiral  nerve. 


Fig.  83. — The  arm  represented  in  the  preceding  figure  dissected  :  the  musculo-spiral 
nerve  and  its  branches  are  transformed  into  a  plexiform  neuroma. 

In  the  limbs  any  nerve  may  be  attacked,  and  the  disease 
is  usually  limited  to  one  nerve,  and  follows  it  out  to  its 
final  ramification. 

One    of    the  most  remarkable  specimens  known    is  pre- 


PLEXIFOBM  NEUROMA  145 

served  in  the  museum  of  the  Middlesex  Hospital;  in  this 
the  musculo-spiral  nerve  is  affected.  The  patient,  a  girl 
of  15  years,  suffered  amputation  of  the  arm  by  Campbell 
de  Morgan.     (Figs.  82  and  83.) 

The  musculo-spiral  nerve  is  as  thick  as  the  thumb ;  it 
looked  gelatinous,  like  an  umbilical  cord.  The  cutaneous 
branches  of  the  nerve  are  very  thick  and  irregularly 
nodulated.  The  microscopic  changes  in  the  musculo-spiral 
nerve  are  identical  with  those  found  in  the  thickened  nerves 
of  a  plexiform  neuroma  underlying  the  pigmented  mother- 
marks.  An  interesting  feature  of  this  specimen  is  the  large, 
smooth,  ovoid  tumour  which  occupies  the  bend  of  the  arm, 
and  is  attached  to  one  of  the  branches  of  the  musculo- 
spiral  nerve. 

Clinical  features. — Neuromas  are  in  the  majority  of 
cases  innocent  tumours ;  they  very  rarely  recur  after  com- 
plete removal  {see  Sarcoma  of  Nerves,  p.  70).  In  exceptional 
environment  a  neuroma  will  cause  death,  and  many  examples 
have  been  observed  in  which  even  small  neuromas  on  the 
roots  of  spinal  nerves  have  produced  paraplegia  with  a  fatal 
ending  (Fig.  81).  Smith  refers  to  a  woman  who  complained 
of  severe  pain  in  the  course  of  the  right  trigeminal  nerve  ; 
this  pain  was  so  much  increased  by  mastication  that  she 
ate  but  little,  and  speaking  aggravated  it  to  such  a  degree 
that  she  remained  silent  unless  interrogated,  and  even  on 
these  occasions  she  often  preferred  to  reply  by  signs.  She 
died  after  enduring  severe  and  uninterrupted  pain  during 
four  and  a  half  months.  At  the  autopsy  a  neuroma  as  large 
as  a  walnut  occupied  the  situation  of  the  right  Gasserian 
ganglion.  With  modern  methods  of  surgery  no  person 
would  be  allowed  to  suffer  in  this  awful  manner. 

The  pain  produced  by  the  painful  subcutaneous  tubercle 
has  already  been  mentioned.  When  a  neuroma  involves  the 
roots  of  a  spinal  nerve,  pain  is  a  prominent  symptom  until 
the  tumour  is  big  enough  to  compress  the  cord  and  pro- 
duce paraplegia :  these  signs  are  not  peculiar  to  neurojiias  of 
the  roots  of  the  spinal  nerves.  Neuromas  on  the  nerves 
of  the  limbs  are  usually  solitar}^,  ovoid ;  the  long  axis  of  the 
tumours  coincides  with  that  of  the  limb  and  produces  pain ; 
when  pressed  the  painful  sensations  radiate  throughout  the 
K 


UQ  GONNEGTIVE-TISSUE    TUMOURS 

distribution  of  the  nerve  below  the  point  of  attachment  of 
the  neuroma. 

In  a  remarkable  case  recorded  b}^  Semon,  an  ovoid 
tumour,  in  all  probability  a  neuroma  of  the  internal  branch 
of  the  superior  laryngeal  nerve,  projected  into  the  ventricle  of 
the  larynx  of  a  woman  40  years  of  age.  The  tumour  was 
noticed  in  1888,  and  it  caused  very  little  trouble  except  when 
pressed  or  handled  (then  coughing  and  retching  occurred 
immediately)  until  1891,  when  it  was  necessary  to  perform 
tracheotomy.  In  1904  Semon  removed  the  tumour  through  an 
incision  in  the  neck,  with  success,  following  the  plan  adopted 
by  Paul  von  Bruns  in  a  similar  case,  which  occurred  in  a  boy 
of  13  years. 

Treatment, — A  solitary  neuroma  in  an  accessible  position 
is  easily  removed,  care  being  taken  during  the  enucleation 
not  to  damage  the  fibres  of  the  nerve.  It  sometimes  happens 
that  the  neuromatous  nature  of  a  tumour  is  not  recognized 
until  after  its  removal  with  a  segment  of  the  nerve.  In  the 
limbs,  such  breaches  in  the  continuity  of  a  nerve-trunk  have 
been  repaired  by  grafting  fragments  of  nerves  from  ampu- 
tated limbs,  or  from  dogs  and  rabbits ;  it  is,  however,  always 
better  to  avoid  this  accident  by  careful  surgery  than  to 
remedy  it  by  secondary  measures,  however  brilliant.  Per- 
sistent facial  palsy  has  followed  the  removal  of  a  neuroma 
lodged  in  the  parotid  gland.  A  neuroma  Avithin  the  spinal 
canal  has  been  successfully  excised. 

Multiple  neuromas,  especially  when  associated  with  mol- 
luscum  fibrosum,  are  beyond  the  art  of  surgery. 

Plexiform  neuromas  have  been  several  times  successfully 
excised :  exceptionally,  when  affecting  a  limb,  amputation  has 
been  found  necessary.  This  form  of  neuroma  in  the  nerves  of 
the  tongue  has  produced  enlargement  of  the  tongue  re- 
sembling macroglossia :  the  condition  was  remedied  by 
excision  of  a  portion  of  the  tongue. 

Friedenwald,  Harry,   "  A  Case  of  Plexiform  Neuroma  of  the  Eyelid  (Ranken- 
iieurom)." — Jolins  Hopkins  Hosp.  RejHs.,  19C0,  ix,  355. 

de  Morgan,  Campbell,  "  Case  of  Multiple  Neuroma  of  the  Forearm." — Trans. 
Path.  Soc,  1S75,  xxvi.  2. 

Semon,  Sir  Felix,  "  Soft  Fibroma  of  the  'L^vjms.."—Brit.  Med.  Jonrn.,  1905, 
i,  tt. 


BEFEBUNGES  147 

Shattock,  S.  G.,  and  Abbott,  F.  C,  "  Macrogiossia  Neuro-Fibromatosa." — Trans. 
Path.  Soc,  liv.  231. 

Sibley,  Septimus  W.,  "  A  Case  of  Multiple  Neuromata  affecting  the  Nerves 
both  within  and  external  to  the  Spinal  Canal." — 'Med.-Chir.  Trans., 
1866,  xlix.  39. 

Thomson,  H.  Alexis,  "  Neuroma  and  Neuro-Fibromatosis." — Edinburgh,  1900. 

Woo6i.~Min.  Med.and  Snrg.  Journ.,  1812,  p.  283. 


CPIAPTER    XIV 

NEUROMAS    AND    ALLIED   CONDITIONS    OF 
THE    NERVOUS    SYSTEM    (Conclwded) 

GLIOMA   OF   THE    BRAIN;    OF    THE    RETINA  AND   OPTIC 
NERYE ;   AND  OF  THE  SPINAL  CORD 

Glioma  of  the  brain. — Ever  since  I  became  practically 
acquainted  with  the  changes  in  the  nerves  constituting  a 
plexiform  neuroma,  it  seemed  to  me  that  they  were  akin 
to  the  localized  neuroglia  overgrowth  in  the  brain  known 
as  glioma,  and  I  was  sufficiently  convinced  of  this  to  draw 
attention  to  the  likeness  in  the  first  edition  of  this  mono- 
graph (1894). 

A  glioma  of  the  brain  occurs  as  a  translucent  swelling 
imperfectly  demarcated  from  the  surrounding  parts ;  the 
gliomatous  tissue  may  have  the  consistence  of  the  vitreous, 
or  be  as  firm  as  the  tissue  of  the  pons.  Microscopically  it 
has  the  characters  of  an  overgrowth  of  neuroglia. 

Yirchow  pointed  out  that  when  a  glioma  is  situated 
near  the  surface  of  the  cerebral  cortex  it  appears  like  a 
colossal  convolution.  Should  it  grow  in  the  tissue  of  an 
optic  thalamus,  this  structure  will  bulge  into  the  third 
ventricle  as  though  overgrown,  and  a  glioma  of  the  occi- 
pital lobe  will  project  into  the  descending  cornu  like  an 
additional  thalamus.  The  best  illustrations  of  this  in- 
definiteness,  so  characteristic  of  gliomas,  come  out  very 
strikingl}^  when  the  pons  and  the  cerebral  crura  are  occu- 
pied by  this  form  of  tumour. 

A  glioma  occasionally  occurs  in  the  pons,  and  forms  a 
tumour  of  considerable  size  (Schorstein).  It  may  be  confined 
to  one  side,  and  extend  into  the  adjacent  cerebellar  crura. 
In  a  case  described  by  Cayley,  which  occurred  in  a  child 
2  years  of  age,  a  glioma  as  large  as  a  walnut  occupied 
the  right  half  of  the  pons  and  extended  along  the  superior 

148 


GLIOMAS 


149 


cerebellar  peduncle  of  that  side,  reaching  as  far  forwards  as 
the  corpora  quadrigemina.  The  gliomatoiis  mass  formed  a 
prominence  on  the  corresponding  half  of  the  floor  of  the 
fourth  ventricle,  and  obstructed  the  Sylvian  aqueduct. 

In  some  cases  both  sides  of  the  pons  are  involved,  and 
the  overgrowth  of  neuroglia  extends  forwards  into  the  cere- 
bral  crura   and  the  cerebellar   peduncles,  and   involves   the 


Fig.  84. — Bilateral  gliomatous  enlargement  of  the  pons  and  crura  cerebri. 
{Angel  Mo)ieij.) 

corpora  quadrigemina.  In  a  few  it  extends  downwards  into 
the  medulla,  and  may  even  involve  the  cervical  portion  of 
the  cord  (Whipham).  Sometimes  the  gliomatous  tissue  is 
so  abundant  as  to  produce  an  enlargement  of  the  pons  and 
cerebral  peduncles.     (Fig.  84  ) 

The  appearance  of  such  brains  is  very  peculiar :  the 
basilar  artery  and  its  branches  appear  as  though  sunk  in 
deep   furrows,  Avhich  cause   the  parts   to   resemble   "  a  soft 


150  GONNECTIVE-TISSVE    TUMOURS 

package  tightly  corded "  (Dickinson).  Such  cases  are  rare, 
and  in  nearly  all  instances  the  patients  have  been  under 
12  years  of  age  (Percy  Kidd,  Gee,  Angel  Money,  and 
Goodhart).  A  case  has  been  observed  in  a  man  of  32 
years  (Schulz).  The  relations  of  a  glioma  to  surrounding 
tissues  are  best  seen  in  recent  specimens.  On  examination 
soon  after  death  the  diseased  parts  are  found  abnormally 
large,  and  on  section  exhibit  a  characteristic  pale-blue 
colour ;  in  thin  sections  the  tissue  has  a  delicate  trans- 
lucent appearance.  The  tumour  itself  is  very  soft,  and 
imparts  to  the  fingers  a  sensation  like  fluctuation.  When 
the  parts  are  immersed  in  alcohol  the  tissue  becomes  firm, 
opaque,  and  white;  under  these  conditions  it  is  particu- 
larly difficult  to  determine  the  limits   of  the  tumour. 

Gliomatous  tumours  of  the  brain  are  purely  local ;  their 
growth  appears  to  be  limited  by  the  cerebral  membranes, 
and  they  do  not  disseminate.  They  vary  greatly  in  structure, 
for  some  consist  mainly  of  round  cells  and  others  are  com- 
posed of  spider  cells ;  in  some  the  cells  are  spindle-shaped. 
They  are  in  no  way  related  to  sarcomas. 

Sarcoma  of  the  optic  nerve. — Tumours  of  the  optic 
nerve  are  very  rare.  A  careful  analysis  of  recorded  cases 
does  not  afford  much  clear  information  on  the  pathologic 
aspect  of  these  tumours,  and  they  are  described  under 
titles  such  as  glioma,  myxoma,  myxo-sarcoma,  fibroma,  and 
sarcoma. 

The  recorded  clinical  facts  are  sufficient  to  prove  that 
tumours  of  connective  tissue  with  malignant  characters  do 
arise  from  and  in  the  optic  nerve.  They  are  unilateral, 
and  more  frequent  in  the  young  than  in  adults.  The 
greater  proportion  are  met  with  before  the  age  of  20, 
and  of  these  by  far  the  larger  proportion  occur  before  the 
tenth  year  of  life. 

The  optic  nerve  is  a  complex  structure,  and  in  the 
embryo  it  is  preceded  by  an  outgrowth  from  the  brain 
known  as  the  optic  stalk ;  this  is  hollow,  and  consists  of 
epithelial  cells.  This  stalk  is  ultimately  replaced  by  a 
fibrous  nerve,  the  nerve  elements  of  which  are  in  part 
derived  from  the  retina  and  in  part,  perhaps,  from  the 
brain  (Robinson).     Thus  the   early  tissue  of  the  optic  stalk 


GLIOMAS  151 

is  identical  in  structure  and  continuous  with  the  susten- 
tacular  tissue  of  the  embryonic  retina. 

These  facts  are  of  importance  because  in  some  cases, 
especially  in  adults,  sarcomas  arise  from  the  sheath  of 
the  nerve,  and  do  not  primarily  involve  the  nerve-fibres. 
Pockley  has  excised  a  tumour  from  the  optic  nerve,  and 
saved  the  nerve  and  the  globe.  The  patient  was  a  boy  ot 
19  years.  The  tumour  is  described  as  an  encapsuled  round- 
celled  sarcoma.  Some  recently  recorded  cases  which  have 
been  very  carefully  investigated  point  to  the  conclusion 
that  many  of  the  tumours  arising  within  the  sheath  of 
the  nerve,  especially  in  children,  are  particularly  connected 
with  the  pial  sheath,  and  in  construction  are  closely  allied, 
if  not  identical,  with  the  retinal  sarcoma  (glioma)  of 
infancy.  The  malignancy  of  optic-nerve  sarcomas,  though 
pronounced,  is  not  excessive. 

Tumours  of  the  optic  nerve  are  usually  ovoid  in  shape, 
with  the  long  axis  coincident  with  that  of  the  nerve. 
Their  surfaces  are  usually  smooth,  and  in  size  they  vary 
greatly,  but  rarely  exceed  a  pigeon's  egg.  They  do  not 
tend  to  invade  the  globe,  but  are  apt  to  creep  through 
the  optic  foramen  and  involve  the  intracranial  portion  of 
the  nerve.  As  the  fibres  of  the  nerve  are  early  implicated, 
vision  is  soon  interfered  with ;  there  is  proptosis,  but  the 
movements  of  the  eye  are  free,  and  there  is  no  pain,  even 
on  manipulation. 

Much  of  the  confusion  relating  to  the  nomenclature 
and  structure  of  tumours  of  the  optic  nerve  is  due  to 
their  rarity,  and  those  interested  in  this  question  will  do 
well  to  study  the  careful  work  of  Treachei-  Collins  and 
Devereux  Marshall. 

Glioma  of  the  retina. — In  structure  this  tumour  mimics 
the  granular  layer  of  the  retina,  and  Treacher  Collins  has 
drawn  attention  to  the  great  similarity  which  exists  between 
the  cells  composing  the  retina  of  the  foetus  at  the  third 
month,  when  its  layers  are  undifferentiated,  and  the  tissue 
of  a  retinal  glioma. 

This  tumour  occurs  exclusively  in  children ;  exception- 
ally it  has  been  detected  at  birth,  more  commonly  it 
makes   its    appearance   during    the   first   four  years  of  life  ; 


152  CONNECTIVE-TISSUE    TUMOURS 

it  is  very  rare  after  the  seventh  year,  and  is  almost  un- 
known after  the  age  of  12.  In  a  certain  proportion  of  cases 
(20  per  cent.)  both  retinae  are  affected,  either  simul- 
taneously or  after  a  brief  interval.  This  is  always  an 
indication  that  the  tumour  is  highly  malignant.  In 
the  early  stages  there  is  usually  no  pain  or  symptom 
denoting  the  presence  of  a  tumour ;  gradually  the  pupil 
dilates,  and  a  peculiar  reflex  is  noted  at  the  fundus  (this 
is  often  termed  cat's-eye),  and,  under  test,  the  eye  will  be 
found  quite  blind.  As  soon  as  the  existence  of  a  glioma 
is  discovered  by  the  surgeon,  the  eye  is,  as  a  rule,  promptly 
excised.  In  cases  where  treatment  of  this  kind  is  refused 
or  deferred,  the  following  changes  occur.  The  tumour^ 
continuing  to  increase,  pushes  forward  the  intra-ocular 
structures  and  causes  great  pain  as  the "  result  of  the  in- 
creased intra-ocular  pressure  it  produces,  until  the  cornea 
fields  and  the  tumour  bursts  forth,  and,  growing  very 
rapidly,  soon  makes  its  way  between  the  eyelids,  which 
become  swollen  and  everted;  and  then,  in  consequence 
of  exposure,  it  assumes  a  dusky  red  fleshy  appear- 
ance, whilst  from  its  surface  a  sanious  fluid  exudes 
which  may  form  crusts  on  the  surface  of  the  tumour. 
Should  the  parts  become  excoriated  or  handled,  they  bleed 
freely.  A  fungating  tumour  of  this  kind  will  sometimes 
attain  a  very  large  size  before  it  destroys  the  child's  life. 

After  excision  of  an  eye  for  retinal  sarcoma  the  dis- 
ease is  very  prone  to  recur,  and  the  recurrent  tumour 
may  attain  very  large  proportions  before  it  destroys  life. 
When  the  operation  has  been  long  delayed  the  growth 
may  have  burst  through  the  sclerotic  and  invaded  the 
orbital  tissues ;  in  a  larger  proportion  of  cases  it  has  infil- 
trated the  optic  nerve,  and  it  is  in  this  structure  that  the 
disease  reappears.  The  frequency  with  which  sarcoma 
returns  in  the  stumjD  of  the  optic  nerve  is,  in  all  prob- 
ability, due  to  the  intimate  lymphatic  relations  of  this 
nerve  with  the  intra-ocular  lymph-spaces. 

In  regard  to  the  question  whether  "glioma"  may ''run" 
in  a  family,  there  is  little  evidence  to  guide  us.  Fuchs 
has  recorded  a  case  in  which  two  children  were  affected  in 
one  family,  and  two  very  extraordinary  reports  have  recently 


GLIOMAS  153 

come  from  Australia.  Earle  Newton  states  that  in  a 
family  of  sixteen  children  ten  died  from  retinal  glioma ; 
three  of  the  cases  were  unilateral  and  seven  bilateral.  All 
the  affected  children,  with  one  exception,  died  about  the 
third  year.  Maher  tells  of  a  family  of  four  children,  of 
whom   three  died  of  glioma,  and  in  two  it  was   bilateral. 

Dissemination  of  retinal  sarcoma  is  exceptional.  The 
common  situations  for  secondary  deposits  are  the  brain, 
the  lymph-glands  about  the  jaws,  and  the  periosteum  of  the 
skull-bones. 

The  treatment  for  retinal  sarcomas  is  removal  of  the  eye, 
and  the  importance  of  promptness  in  this  matter  is  indicated 
in  the  careful  inquiry  conducted  by  Lawford  and  Collins. 
They  prove  very  clearly  the  following  points  : — 

The  quicker  an  eye  is  removed  after  the  discovery  of  the 
disease,  the  better  the  prospect  of  cure.  In  the  majority  of 
cases  the  disease  returns  in  the  orbit,  and  in  a  very  small 
proportion  of  cases  secondary  deposits  occur  in  other  parts. 
When  recurrence  takes  place  it  is  rarely  delayed  beyond  nine 
months ;  but  one  undoubted  case  has  been  reported  in  which 
the  disease  returned  three  years  after  the  primary  operation. 
If  three  years  elapse  and  there  is  no  recurrence,  the  recovery 
may  be  regarded  as  permanent.  Out  of  fifty-four  cases  in 
Lawford  and  Collins's  list,  eight  patients  were  alive  and  free 
from  recurrence  three  years  after  the  removal  of  the  eye  for 
retinal  glioma.  It  is  significant  to  note  that  in  seven  of 
these  cases  the  disease  affected  one  eye  only.  This  shows 
the  almost  hopeless  condition  of  the  patient  when  both 
eyes  are  affected. 

Other  statistical  inquiries  have  been  conducted  with  the 
view  of  obtaining  the  percentage  of  cures  in  this  disease,  and 
they  work  out  at  about  the  same  proportion  as  in  the  paper 
mentioned  above. 

Glioma  of  the  spinal  cord. — A  glioma  of  the  spinal 
cord  is  a  very  rare  tumour,  and,  judging  from  the  scanty 
records,  it  would  appear  that  a  glioma  in  the  brain  is  twenty 
times  more  frequent  than  in  the  cord.  The  tumour  is  im- 
perfectly demarcated  from  the  nervous  tissue,  and  often 
causes  a  general  enlargement  of  the  cord,  producing  upon 
it  an  effect  like  gliomatous  disease  of  the  pons,  crura,  and 


154  G0NNEGTIVE-TI8SUE    TUMOURS 

medulla.  It  was  pointed  out  in  connexion  with  this  disease 
of  the  medulla  that  it  sometimes  involves  the  adjacent 
segment  of  the  spinal  cord. 

Resinger  collected  and  epitomized  the  records  of  nineteen 
cases  of  glioma  of  the  spinal  cord,  and  added  a  full  descrip- 
tion of  a  case  which  he  observed  ;  the  report  is  accompanied 
by  an  account  of  the  morbid  anatomy  of  the  parts  by  Prof 
Marchand. 

The  disease  may  attack  any  part  of  the  cord,  but  is  most 
frequent  in  the  cervical  enlargement.  In  a  few  instances  the 
tumour  was  seated  in  the  lumbar  region.  It  appears  most 
frequently  between  the  seventeenth  and  thirtieth  years,  but 
it  has  been  observed  as  late  as  50.  Sharkey  has  published 
an  interesting  account  of  a  spinal  glioma  which  occurred 
in  a  man  50  years  old,  and  he  uses  it  to  demonstrate  the 
clinical  fact  that  when  a  tumour  arises  within  the  cord,  as, 
gliomas  always  do,  it  disturbs  its  functions  from  the 
commencement ;  but,  as  the  nerve  substance  appears  to  be 
elastic,  and  to  allow  a  good  deal  of  gradual  stretching 
without  serious  interference  with  its  functions,  a  tumour  may 
continue  to  grow  for  a  long  time  before  it  produces  striking 
pathologic  phenomena.  When  a  tumour  grows  in  the  spinal 
canal  outside  the  cord  it  may  produce  but  few  symptoms 
until  it  presses  the  cord  against  the  resisting  Avails  of  the 
canal ;  after  this  has  taken  place  the  course  of  the  disease  is 
naturally  very  rapid,  as  the  cord  is  quickly  flattened  by  the 
constantly  increasing  demands  for  growing-space  which  are 
made  by  the  tumour. 

The  peculiar  relation  of  the  gliomatous  tissue  to  the  nerve- 
tissue  of  the  cord  precludes  any  surgical  interference. 

Cayley,  W.,  "  Gliomatous  Tumours  of  the  Brain." — Trans.  Path,  Soc,   1865, 
xvi.  23. 

Collins,  Treacher,  "  Anatomy  and  Physiology  of  the  Eye,"  1896,  p.  84. 

Gee,  S.,  "  A  Second  Case  of  Gelatiniform  Enlargement  of  the  Pons  Varolii."— 
St.  Bart.'s  Hosp.  Mepts.,  1881,  xvii.  287. 

Groodhart,  James  F.,  "  Cases  of  Cerebral  Tumour." — Trans.  Path.  Soc,  188G, 
xxxvii.  14. 

Kidd,  Percy,  "A  Case  of  Great  Enlargement  of  the  Pons,  Crura  Cerebri,  and 

Medulla."— ,%.  Bart.'s  Hasp.  Mepts.,  1877,  xiii.  271. 
Lxwford,  J.  B.,  and  Collins,  E.  Treacher,    "  Notes  on  Glioma  Retinse,  with  a 

report  of  GO  Cases."— i^^'y.  Land.  Ophthal.  Eosp.  Rejrts.,  1893,  xiii.  12. 


BEFEBENGES  155 

Maher,  Anstralaslan  Med.  Gac,  1902. 

Marshall,  Devereux,  "  Further  Note  on  a  Case  of  Optic  Nerve  Tumour  pre- 
viously reported  to  the  Society." — Trans.  OphtTial.  Soc,  1900,  xx.  164. 

Marshall,  Devereux,  "  Implantation  Cysts  of  the  Iris." — Trans.  OjiJdhal.  Soc, 
1899,  xix.  54. 

Money,  Angel,  "  Gliomatous  Enlargement  of  the  Pons  Varolii  in  Children." — 
MeoL.-Chir.  Trans.,  1883,  Ixvi.  283. 

Newton,  Earle,  Australasian  Med.  Gaz.,  1902. 

Pockley,  Australasian  Med:  Gaz.,  Oct.  1901. 

Resinger,  "  Ueber  das  Gliom  des  Riickenmarkes,  Beschreibung  eines  Hirner- 
gehorigen  Falles,  mit  anatomischer  Untersuchung  von  Prof.  Marchand." 
— Virchow's  AreJi.  f.path.  Anat.,  1884,  xcviii.  3G9. 

Schorstein,  G.,  and  Watson,  A.  J.,  "A  Case  of  Glioma  of  the  Pons." — Lancet, 
190G,  i.  1035. 

Schulz,  Richard,  "  Gliomatose  Hypertrophie  des  Pons  und  der  Medulla 
Oblongata." — ■Neuroloijisches  Centralbl.,  1883,  ii.  5.  (This  paper  con- 
tains several  references.) 

Sharkey,  S.  J.,  "  Spasm  in  Chronic  Nerve  Disease." — Guhtonian  Lectures,  188G, 
pp.  53-58. 

Whipham,  T.,  "  Tumour  (Glioma)  of  the  Spinal  Cord  and  Medulla  Oblongata  : 
Dilatation  of  the  Lymphatics ;  Large  Cavity  occupying  the  position 
of  the  Central  Canal  (Syringomyelus)."  —  Trans.  Path.  Soc,  1881, 
xxxii.  8. 


CHAPTER   XV 
ANGEIOMA    AND    LYMPHANGEIOMA 

ANGEIOMAS 

An"  angeioma  is  a  t-umour  comjiosed  of  an  abnormal  forma- 
tion of  blood-vessels. 

This  genus  contains  three  species : 

1 .  Simple  ncevus. 

2.  Cavernous  noevus. 

3.  Plexiform  angeioma. 

1.  Simple  naevus. — This  is  the  most  common  species  of 
nsevus,  and  in  its  typical  form  affects  the  skin  and  sub- 
cutaneous tissue.  A  ngevus  may  aj)pear  as  a  superficial 
discoloration  of  the  skin,  and  is  either  a  lively  pink  or  a 
deep  blue :  these  are  known  as  "  port-wine  stains."  Such 
nsevi  may  involve  an  area  of  skin  2  cm.  scjuare,  or  extend 
over  a  large  portion  of  the  face,  or  half  the  trunk,  or  be 
restricted  to  a  limb.  James  II.  of  Scotland  had  a  stain  on 
one  cheek  and  was  called  "Fiery-Face." 

A  very  common  variety  of  nsevus  is  that  often  referred  to 
as  telang-eiectasis;  it  consists  of  an  abnormal  collection  of 
arterioles  situated  in  the  skin  and  subcutaneous  tissue;  it 
may  be  present  at  birth,  but  much  more  frequently  appears 
in  the  course  of  the  first  few  weeks  of  life.  Sometimes  a 
nsevus  appears  as  a  red  spot  no  larger  than  a  split  pea;  then 
suddenly  it  grows  actively,  and  'in  two  or  three  months  will 
involve  an  area  of  skin  4  cm.  square.  When  the  nsevus 
consists  mainly  of  arterioles  it  will  be  bright  pink;  when 
composed  mainly  of  venules  it  will  be  of  a  bluish  tint. 
Lymphatics  are  often  present.  Structurally,  nsevi  are  com- 
posed of  minute  blood-vessels  embedded  in  fat;  usually  two 
or  more  large  vessels  establish  a  communication  between 
the   nsevus   and    an   adjacent   artery   or   vein.     The   vessels 

156 


ANGEI0MA8  157 

of  the  nfevus  are  often  sacculated.  When  gently  compressed, 
the  blood  is  driven  from  the  nsevus,  which  at  once  loses 
its  colour ;  but  the  colour  returns  as  soon  as  the  pressure 
is  relieved. 

Simple  nffivi  are  common  enough  in  the  skin  of  the  face, 
scalp,  neck,  and  back.  They  are  less  frequent  on  the  limbs. 
They  also  occur  on  the  labia,  the  lips,  tongue,  and  conjunctivae. 

NtBvi  of  small  size  frequently  disappear  spontaneously ; 
more  often  they  gradually  increase  in  size,  and  may  become 
converted  into  cavernous  nyevi,  or  endotheliomas  (Chap.  xli.). 

2.  Cavernous  nsevus. — This  is  the  species  to  which  the 
term  erectile  tumour  is  most  applicable.  In  structure  it 
is  comparable  to  the  spongy  tissue  characteristic  of  the 
cavernous  tissue  of  the  penis.  Cavernous,  like  simple  na^vi 
are  most  frequently  seen  in  connexion  with  the  skin,  where 
they  form  distinct  tumours  of  a  red  or  blue  colour,  rising- 
above  the  general  surface ;  sometimes  they  display  the 
peculiar  tint  so  characteristic  of  fluid  contained  in  thin- walled 
cysts,  for  which  a  cavernous  nsevus  is  often  mistaken,  especi- 
ally when  situated  near  the  outer  angle  of  the  orbit.  In  most 
cases  the  blood  can,  by  firm  and  steady  pressure,  be  squeezed 
out  of  a  nsevus,  but  the  swelling  quickly  reappears  after  the 
compression  is  removed.  The  surface  of  a  nsevas  may  feel 
warmer  than  the  surroundinof  skin,  and  sometimes  the  tumour 
pulsates,  the  movement  being  appreciable  to  the  finger,  and 
occasionally  perceptible  to  the  eye. 

Structurally,  cavernous  na^vi  are  made  up  of  variously 
shaped  spaces  and  sinuses,  the  walls  of  which  are  merely 
fibrous  septa,  lined  with  endothelium.  Some  of  these  nsevi 
consist  in  part  of  vessels  and  in  part  of  cavernous  spaces. 
When  an  angeioma  consists  entirely  of  irregular  blood-con- 
taining spaces,  a  dissection  round  its  periphery  will  reveal  the 
existence  of  vessels,  sometimes  of  considerable  size,  conveying 
blood  to  it  from  adjacent  arteries.  Cavernous,  like  simple 
ntevi  are,  as  a  rule,  congenital,  but  a  nasvus  which  during 
infancy  is  small  and  inconspicuous  may  later  in  life  become 
converted  into  a  cavernous  nsevus  of  lars^e  size,  and  one  that 
will,  under  certain  conditions,  jeopardize  life.  Verj^  large 
cavernous  mevi  have  been  observed  in  the  breast,  in  the 
male  as  well  as  in  the  female. 


158  CONNECTIVE-TISSUE   TUMOURS 

Cavernous  nsevi  occasionally  occur  in  tlie  tongue ;  as  a 
rule,  they  are  situated  near  the  surface,  and  form  slightly 
elevated  patches  of  a  deep-blue  or  livid  colour.  Such  nsevi 
rarely  give  rise  to  any  difficulty  in  diagnosis :  their  colour, 
general  apj^earance,  and  the  fact  that  firm  pressure  suffices 
to  drive  the  blood  out  of  the  tumour  are  sufficient  to 
indicate  their  ntevous  character.  Many  lingual  nrevi  are 
congenital,  but  a  fair  proportion  originate  late  in  life.  It 
must  also  be  borne  in  mind  that  a  small  and  inconspicuous 
naevus  may,  as  years  run  on,  develop  almost  silently  into  a 
dangerous  erectile  tumour. 

In  some  instances  lingual  nsevi  cause  very  little  incon- 
venience unless  they  bleed,  but  this  accident  may  arise 
at  any  time,  either  by  abrasion  from  hard  food  or  from 
accidental  bites,  or  in  consequence  of  rubbing  against 
jagged  teeth.  Under  such  conditions  the  ha3morrhage  is 
sometimes  very  alarming,  and  so  oft-repeated  that  it  is  in 
some  instances  imperative  to  excise  the  implicated  half  of 
the  tongue.  Except  in  the  tongue  and  rectum,  cavernous 
nsevi  are  very   rare  in  mucous  membranes. 

Cavernous  angeiomas  are  sometimes  found  in  voluntary 
muscles.  Several  interesting  examples  were  collected  and 
described  by  Campbell  de  Morgan   in  1864 

Examples  have  been  observed  and  carefully  recorded  in 
the  following  muscles :  the  semimembranosus,  semitendi- 
nosus,  and  deltoid ;  and  Eve  has  removed  one  involving  the 
triceps  and  anconeus.  The  museum  of  the  Royal  College 
of  Surgeons  contains  an  example  removed  by  Stonham 
from  the  gracilis. 

Rau  has  described  a  cavernous  angeioma  which  occupied 
the  wall  of  the  right  auricle ;  the  patient  was  56  years  of 
age,  and  the  tumour  equalled  in  size  a  small  cherry,  and 
occupied  the  deep  layers  of  the  endocardium. 

Cavernous  angeiomas  are  of  very  rare  occurrence  in 
the  larynx;  nevertheless  they  have  been  observed  in  this 
situation,  and  the  careful  descriptions  of  some  of  the  cases 
place  the  nature  of  the  tumour  beyond  doubt.  They  have 
been  observed  springing  from  the  vocal  cords  (Percy  Kidd), 
the  ventricular  bands,  and  from  the  ventricle.  The  most 
striking  examples  arise  in  the  sinus  pyriformis.     Usually  such 


ANGE10MA8  159 

tumours  are  sessile,  but  they  are  occasionally  pedunculated ; 
they  may  be  bright-red  or  purple.  Laryngeal  angeiomas 
may  be  smooth  or  nodulated  like  a  mulberry ;  they  are 
rarely  larger  than  a  haricot  bean.  The  colour  of  these 
tumours   is  the  most  striking  clinical  feature. 

An  extremely  rare  situation  for  a  cavernous  navus  is 
the  subperitoneal  tissue  (Lane) ;  another  is  the  synovial 
membrane  of  the  knee-joint,  simulating  tuberculous  disease 
of  that  joint  (Eve). 

The  liver  is  not  an  unusual  situation  for  cavernous 
npevi  of  small  size.  Nsevi  are  not  uncommon  in  the  livers 
of  cats  and  feline  mammals  in  general,  but  they  appear  to 
be    harmless  tumours. 

3.  Plexiform  angeioma. — The  angeiomas  which  will 
be  included  under  this  denomination  are  those  usually 
designated  as  "  aneurysms  by  anastomosis,"  or  "  cirsoid 
aneurysms."  The  former  term  appears  to  have  been  intro- 
duced by  John  Bell,  but  the  expression  "aneurysm  by 
anastomosis "  has  come  to  be  used  so  vaguely  that  its 
suppression  is  a  matter  of  necessity. 

A  plexiform  angeioma  consists  of  a  number  of  abnormal 
blood-vessels  of  moderate  size  arranged  parallel  to  each 
other,  as  in  the  rete  mirabile  of  the  fore  limb  of  the  sloth 
or  the  tail  of  a  spider  monkey.  Such  angeiomas  may 
consist  of  arteries  only'  (arterial  retia),  or  of  veins  (venous 
retia),  or  of  arteries  and  veins  in  equal  proportions  (duplex 
retia).  In  some  the  vessels  are  very  tortuous,  a  disposition 
more  common  with  arteries  than  veins.  Tortuous  vessels 
are  not  infrequent  in  retia — for  example,  the  arterial  retia 
in  the  intercostal  spaces  beneath  the  pleura  of  cetaceans, 
and  the  rete  in  the  pituitary  fossa  of  oxen  and  sheep ;  and 
the  renal  glomerulus. 

Plexiform  angeiomas  are  very  rare ;  the  largest  that 
has  come  under  my  notice  occurred  in  the  perineum  of  a 
lad  19  3'ears  of  age :  the  corpus  spongiosum  was  sur- 
rounded by  a  number  of  arteries  as  large  as  the  coronary 
branches  of  the  facial,  and  veins  as  big  as  the  cephalic. 
The   arrangement  resembled  that  of  a  duplex  rete. 

Miiller  has  recorded  very  carefully  the  clinical  history 
and   an   account    of    the    subsequent   dissection    of    a    very 


160 


GONNEGTIVE-TISSUE   TUMOURS 


unusual  example  of  plexiform  angeioma.  The  patient,  a 
man  of  20  years,  stated  that  his  parents  noticed  a  red  spot 
on  the  left  half  of  the  forehead  when  he  was  a  year  old ; 
this  gradually  increased  in  size,  and  at  the  age  of  12  it 
had  become  an  obvious  tumour.  When  the  patient  was 
16  it  not  only  grew  rapidly,  but  began  to  "  buzz."  At 
the   age    of  20    the    tumour    exhibited   all    the    characters 


Fig.  85. — Dissection  of  a  plexiform  angeioma  of  the  forehead.    (j4fter  H.  Mullo:) 


of  a  plexiform  angeioma,  the  pulsation  being  attended  by 
a  whirring  sound.  P.  Bruns  ligatured  the  right  external 
carotid  and  the  left  common  and  external  carotid.  The 
patient  became  hemiplegic  on  the  second,  and  died  on  the 
third  day  after  the  operation.  Death  was  due  to  embolism 
and  thrombosis  of  the  left  middle  cerebral  artery.  The 
parts  were  injected  and  dissected  (Fig.  85) ;  the  angular 
arteries   were   large   and  very  tortuous. 

Plexiform     angeiomas    occur    in    connexion    with     the 


ANGEIOMAS  161 

cerebral  arteries.  They  have  been  observed  on  the  surface 
of  the  right  anterior  lobe  of  the  cerebrum,  fed  mainly  by 
the  anterior  and  middle  cerebral  arteries.  In  two  cases 
reported  by  Drysdale,  one  patient  was  a  lad  17  years  of 
age,  and  the  other  a  woman  aged  26  years.  The  woman 
was  an  epileptic.  In  another  patient,  a  man  aged  20,  the 
angeioma  was  situated  over  the  angular  gyrus:  the  patient 
died  from  hoemorrhage  from  the  tumour,  which  produced 
the  typical  signs  of  pressure  on  the  motor  region  of  the 
cortex  (D'Arcy  Power).  A  cavernous  angeioma  has  been 
observed  in  the  temporo-sphenoidal  lobe  of  the  brain  of  a 
male  epileptic  idiot  aged  8  (Dobson). 

Treatment.  —  Nsevi  come  under  observation  almost 
daily ;  in  such  cases  it  is  usual  to  watch  the  child  in  order 
to  ascertain  whether  the  nasvus  is  growing  or  not:  manynsevi 
disappear ;  but  when  they  become  active  and  grow,  they 
need  prompt  treatment.  No  method  is  so  safe  and  effectual 
as  excision,  whenever  it  can  be  carried  out,  remembering 
always  to  cut  the  ncevus  out,  not  cut  into  it.  I  have 
excised  nsevi,  simple  and  cavernous,  from  the  skin  over  an 
unclosed  fontanelle,  the  eyelids,  the  tongue,  labium,  and 
other  parts  of  the  body  in  more  than  one  hundred  chil- 
dren, and  never  had  the  least  untoward  symptom.  It  is 
infinitely  preferable  to  treatment  by  electrolysis,  nitric  acid, 
ethylate  of  sodium,  or  the  ligature.  The  chief  reason  for 
excising  n^evi  when  they  evince  signs  of  activity  is  to 
prevent  them  from  assuming  such  proportions  as  to  pass 
beyond  the  limits  of  justifiable  surgery.  Many  examples 
have  been  recorded  in  which  a  nsevous  fleck  in  an  infant 
has  become  a  formidable   tumour   in  the   adult. 

The  nsevi  which  are  known  as  "  stains "  disappear  under 
the  influence  of  radium, 

It  is  impossible  to  advise  in  regard  to  the  treatment  of 
plexiform  angeioma.  Each  case  exhibits  special  features 
which  will  modify  the  operation,  and  the  particular 
]nethod  employed  will  depend  on  the  enterprise,  experi- 
ence, and  skill  of  the  surgeon  in  charge  of  the  case. 
Several  cases  of  plexiform  angeioma  of  the  limbs  have  been 
recorded  in  which  it  has  been  necessary  to  resort  to 
amputation.  When  the  leg  is  involved  this  operation  is 
L 


162  CONNECTIVE-TISSUE   TUMOURS 

attended  with  unusual  risk  of  life.  The  operative  difficulties 
and  dangers  in  connexion  with  large  plexiform  angeiomas 
of  the  head  and  orbit  are  very  great. 


LYMPHANGETOMAS 

A  lymphangeioma  has  the  sanae  relation  to  lymphatics 
that  an  angeioma  bears  to  hsemic  capillaries. 
There  are  three  species  of  lymphangeiomas : 

1.  Lymphatic  nsevus. 

2.  Cavernous  lymphangeioma. 

3.  Lymphatic  cyst. 

1.  Lymphatic  nsevus.— This  species  of  lymphangeioma 
is,  as  a  rule,  colourless,  but  when  it  contains  a  fair 
number  of  h^emic  capillaries,  then  the  nsevus  appears  as 
a  pale  pink  patch  slightly  raised  above  the  level  of  the 
surrounding  skin.  When  composed  entirely  of  lymphatics 
it  is  yellowish-white  ;  when  it  is  pricked,  lymph  (sometimes 
mixed  with  blood)  issues  from  it.  Occasionally  several 
nsevi  occur  in  the  same  individual ;  they  vary  greatly  in 
size — some  are  as  small  as  shot,  others  may  have  a 
diameter  of  2  cm.  or  more.  In  many  instances  they  are 
noticed  a  few  months  after  birth ;  occasionally  they  seem 
to  be  acquired.  This  is  probably  explained  on  the  ground 
that  during  infant  life  they  are  small,  and  their  want  of 
colour  saves  them  from  detection  until  their  increase  in 
size  later  in  life   makes   them  conspicuous. 

Lymphatic  nsevi  may  occur  in  the  skin  on  any  part  of 
the  trunk  or  limbs,  and  have  been  especially  studied  in 
the   mucous  membrane  of  the  tongue  and  lips. 

In  connexion  with  the  tongue  the  affections  may  be 
localized  to  a  definite  area  and  give  rise  to  a  lingual 
lymphangeioma ;  this  takes  the  form  of  a  pale  -  pink 
papilla,  or  clusters  of  smooth  papillae,  projecting  from  the 
mucous  membrane.  Sometimes  one  half  of  the  dorsum 
of  the  tongue  will  be  beset  with  small  rounded  projections. 
These  projections  consist  of  clusters  of  dilated  lymphatic 
vessels. 

There  is  a  very  rare  disease  of  the  tongue  to  which 
the  name  macroglossia  is   applied.     Clinically  the   condition 


L  YMPHANGEIOMAS 


163 


manifests  itself"  as  a  congenital  enlargement  of  the  tongue 
implicating  mainly  its  anterior  two-thirds.  As  the  child 
grows  the  tongue  increases  so  disproportionately  that  the 
mouth  accommodates  it  with  difficulty,  and  at  last  the 
tip  of  the  organ  protrudes  from  the  mouth  and,  in  severe 
examples,  becomes  so  big  as  to  extend  far  beyond  the 
margins  of  the  lips  (Fig.  86). 


Fig.  86.  — Macroglossia  in  a  girl  aged  11.     {After  Humphrij.) 

The  increase  in  the  size  of  the  tongue  is  not  due  to 
an  overgrowth  of  its  muscular  substance,  but  is  caused,  as 
Virchow  pointed  out,  by  the  formation  of  a  lymphangeioma 
in  connexion  with  the  lingual  mucous  membrane. 

Recent  observations  have  shown  that  there  is  another 
cause  of  macroglossia,  namely,  plexiform  neuroma  affecting 
the  lingual  and  hypoglossal  nerves  (p.  143). 

2.   Cavernous    lymphangeioma.  —  This    species    in    its 


164 


GONNEGTIVE-TISSVE   TUMOURS 


naked-eye  cliaracters  resembles  a  lympliatic  nseviis,  but  on 
microscopical  examination  it  will  be  found  to  be  identical 
in  structure  with  the  cavernous  nsevus,  with  the  difference 
that  its  cavities  are  filled  with  lymph  instead  of  blood. 

Treatment. — -This  is  conducted  on  the  same  lines  as  for 
angeiomas.  In  the  case  of  macroglossia,  excision  of  the 
enlarged  and  protruding  parts  of  the  organ  has  been  followed 
by  permanent  good  consequences. 


Fig.  87.— Lymphatic  cyst  of  the  neck  iu  a  child  2  years  of  age. 


3.  Lymphatic  cyst. — This  appears  as  a  congenital  swelling 
in  the  neck,  axilla,  and  adjacent  parts  of  the  thoracic  wall ; 
it  was  formerly  classed  under  the  title  "hydrocele  of  the 
neck." 

Lymphatic  cysts  are  easily  recognized.  They  are  always 
congenital ;  even  at  birth  they  are  sometimes  of  very  large 
size,  and  exhibit  a-  preference  for  the  anterior  triangle.  In 
some  instances  they  extend  into  the  axilla  and  superior  medi- 
astinum, or  project  into  the  posterior  triangle  (Fig.  87). 
Their  upward  limit  is,  as  a  rule,  indicated  by  the  hyoid  boue, 
but  they  have  been  known  to  reach  as  high  as  the  parotid 


LYMPHATIC   CYSTS 


165 


gland.  The  cyst  may  be  unilateral  or  bilateral  ;  it  may 
consist  of  a  single  cavity,  or  be  multilocular  and  the  various 
chambers  may  intercommunicate.     In  size  they  vary  greatly  : 


J3utte|=vA 


Fig.  88.  —Child  with  a  lymphatic  cyst  on  the  side  of  the  thorax  which  probably 


arose  m  an  angeioma. 


166  CONNECTIVE-TISSUE  TUMOURS 

some  equal  a  fist,  others  are  bigger  than  the  head  of  the 
patient.  When  the  walls  of  the  cyst  are  thin  and  the  over- 
lying skin  is  stretched,  the  tumour  is  as  translucent  as  a 
thin-walled  hydrocele  of  the  tunica  vaginalis  testis. 

These  cysts  originate  below  the  deep  cervical  fascia,  but  a 
portion  may  make  its  way  through  this  membrane  and 
become  subcutaneous. 

Perhaps  the  most  remarkable  fact  in  connexion  with 
them  is  the  tendency  they  exhibit  to  shrivel  and  dis- 
appear ;  they  are  exceptionally  liable  to  inflame,  and 
several  cases  have  been  recorded  in  which  the  cyst  has 
been  ruptured  by  the  child  falling  upon  it.  Their  proneness 
to  spontaneous  cure  explains  the  rarity  of  such  cysts  after 
puberty. 

It  has  been  many  times  observed  that  the  spontaneous 
effacement  of  these  cysts  is  preceded  by  a  sudden  increase  in 
their  size  ;  they  become  hot,  tender,  and  pass  into  a  state 
of  inflammation,  and  as  this  subsides  the  cysts  slowly 
disappear. 

The  walls  of  lymphatic  cysts  are  often  composed  of  tissue 
so  vascular  as  to  merit  the  term  nsevous ;  it  is  probable  that 
some  of  them  have  arisen  in  large  cavernous  nsevi  which 
have  been  converted  into  cysts  (Fig.  88). 

It  is  important  to  remember  that  lymphatics  are  often 
very  abundant  in  the  ordinary  forms  of  cavernous  nsevi.  It  is 
also  a  fact  of  some  interest  that  a  lymphatic  cyst  in  the  neck 
and  well-marked  macroglossia  have  been  observed  in  the 
same  individual. 

Barker,  A.  E.,  "Cavernous  Nsevus  of  the  Eectum  proving  Fatal,  in   an  Adult, 

from  Hsemorrhage." — Med.-Chir.  Trans.,  1883,  Ixvi.  229. 
Barker,   A.   E.,  "A  Case  of  Macroglossia,   so-called  Lymphangioma   Caver- 

nosum." — Trans.  Path.  Soe.,  1890,  xli.  77. 
Bland-Sutton,  J.,  "  A  Case  of  Erectile  Tumour  of  the  Male  Breast." — Trans. 

Clm.Soc,  1889,  xxii.  187. 
Dobson,  Margaret  B.,  "A  Cavernous  Angioma  of  the  Temporo-Sphenoidal  Lobe 

of  the  Brain."— ^ri^.  Med.  Journ.,  1907,  ii.  144. 
Drysdale,  J.  H.,  "  Angioma  Arteriale  Racemosum  :  Two  Cases." — Trans.  Path. 

Soc,  1904.  Iv.  66. 
Griffiths,  J.,  "  Case  of  Villous  Sarcoma  of  the  Neck  and  Heart." — Trans.  Path. 

Soc,  1888,  xxxix.  311. 
Humphry,  G.  M.,   "Hypertrophy  and  Prolapse  of  the  Tongue." — Med.-Chir. 

Trans.,  1853,  xxxvi.  113. 


BEFEBENGES  167 

Image,  W.   E.,  "  A  Case  of  Enlargement  of  the  Left  Mamma.     To  which  is 

added  an  Anatomical  and  Pathological  Description  of  the  Tumours  by 

T.   G.   Hake,  M.D.,  and  VV.  E.  Image.    Communicated  by  Robert  Liston, 

'F.B..S."—Med.-CMr.  Trans.,  1817,  xxx.  105. 
Eidd,  Percy,  "Cavernous  Angioma  of  the  Larynx." — Trans.  Clin.  Sue.  Lond., 

1892,  XXV.  307. 
Lane,  W.  A.,  "A  Case  of  Extensive  Nsevus  of  the  Peritoneum." — Trans.  Clin. 

Soc,  1893,  xxvi.  5. 
de  Morgan,  Campbell,  "  Remarks  on  some  Cases  of  Vascular  Tumour  seated 

in  Muscle." — Brit,  and  -For.  Med.  and  CMr.  Bev.,  1864,  xxxiii.  187. 
MtlUer,  H.,  "  Ein  Fall  von  arteriellem  Rankenangiom   des  Kopfes." — Beit. 

z.  Idin.  CMr.,  1892,  viii.  79. 
Power,  D'Arcy,  "Angioma  of  the  Cerebral  Membranes." — Trans.  Path.  Soc., 

1888,  xxxix.  4. 
Rau,  F.,  "  Gasuistische  Mittheilungen  von  den  Prosectur  des  Katharinenhos- 

pitals    in   Stuttgart  (Cavernoses   Angiom  im   rechten   Herz-Vorhof)." — ■ 

Virchow's  Arch.,  1886,  cliii.  22. 


CHAPTER    XYI 
UTERINE    FIBROIDS 

The  tumours  of  the  uterus  known  as  fibroids,  myomas,  or 
fibro-myomas  are  extremely  common,  and  on  account  of  the 
difficulties  and  dangers  which  arise  from  them,  directly  and 
indirectly,  their  pathological  and  clinical  aspects  have  been 
studied  with  very  gi'eat  care.  Before  minutely  describing  the 
structural  peculiarities  of  fibroids,  it  will  be  of  some  advantage 
to  study  their  topography  and  gross  anatomy.  Though 
fibroids  arise  in  every  part  of  the  uterus,  including  its  liga- 
ments, they  are  more  common  in  the  body  of  the  organ  than 
in  its  neck.  Those  which  arise  in  the  cervix  offer  peculiar 
features  and  demand  separate  consideration. 

Fibroids  of  the  body  of  the  uterus.— Tumours  origin- 
ating in  the  uterine  walls  may  be  single  or  inultiple.  In 
their  early  stages  they  resemble  in  section  knots  in  a  piece 
of  wood.  These  tumours  are  firm,  often  hard,  and  always 
encapsuled. 

For  clinical  purposes  it  is  convenient  to  divide  them 
into  three  sets,  according  to  the  part  of  the  uterus  in  which 
they  arise  : — 

1.  In  the  wall  of  the  uterus :  such  are  termed  inter- 

stitial or  intramural. 

2.  In  the  endometrium :  these  are  said  to  be  submucous. 

3.  In  the  layer  of  muscle-tissue  subjacent  to  the  peri- 

toneum :  these  are  termed  subserous. 

Fibroids  may  arise  in  and  remain  confined  to  any  one  of 
these  situations,  or  all  the  varieties  may  be  seen  in  the  same 
uterus ;  and  there  is  no  limit  to  their  number.  I  have 
counted  one  hundred  and  forty  fibroids  in  one  uterus ;  they 
varied  in  size  from  a  dove's  egg  to  that  of  a  duck. 

It  not  infrequently  happens  that  when  a  fibroid  is  confined 

168 


VTEBtNE  FIBROIDS  169 

to  one  wall  ol  the  uterus  and  appears  as  a  single  tumour 
externally,  it  will  be  found  on  section  to  consist  of  two  or 
more  tumours  growing  in  association,  but  eacb  possessing  its 
own  capsule.  Such  may  be  conveniently  called  conglomerate 
fibroids. 

1.  Interstitial   fibroids. — This  variety  may  occur  singly  or 
in  multiple.     Such  tumours  in  their  early  stages  resemble,  in 


Fig.  89. — Uterus  in  sagittal  section  showing  interstitial  and 
submucous  fibroids. 

section,  knots  in  wood ;  they  have  distinct  capsules,  and  are 
firm  and  even  hard  to  the  touch.  The  bundles  of  spindle- 
celled  tissues  are  usually  interwoven  in  such  a  manner  as  to 
present  a  very  characteristic  whorled  appearance.  There  is 
no  limit  to  their  growth,  and  they  sometimes  attain  a  large 
size,  and  may  weigh  upwards  of  twenty  and  even  thirty 
kilogrammes. 

2.  Submucous  fibroids.  —  These  tumours  arise  in  the 
deeper  parts  of  the  endometrium,  and,  when  they  attain  an 
appreciable  size,  project  into   the  cavity  of  the  uterus  and 


170 


CONNECTIVE-TISSUE   TUMOURS 


give  rise  to  one  variety  of  "fleshy  polypus  of  the  womb." 
Submucous  tibro-myomas  are  at  first  sessile  and  invested  on 
that  surface  which  projects  into  the  cavity  of  the  uterus 
with  mucous  membrane.  As  they  increase  in  size  they  dilate 
the  uterine  cavity  and  tend  to  become  pedunculated. 


Fig.  90. — Very  vascular  fibroid  in  section.     {After  Virchoiv.) 

The  presence  of  the  tumour  within  the  uterus  leads  to 
great  thickening  of  the  walls,  accompanied  by  increased  vas- 
cularity, which  is  often  manifested  by  irregular  haemorrhage 
from  the  uterus,  or  at  least  by  profuse  menstruation.  Sub- 
mucous fibroids  are  sometimes  so  vascular  as  to  resemble  a 
cavernous  nsevus  on  section  (Fig.  90). 

The  pedicle  of  a  submucous  fibroid  may  become  sufficiently 
elongated  to  allow  the  tumour  to  pass  through  the  cervical 
canal  into  the  vagina,  and  even  protrude  at  the  vulva.  When 
this  happens  an  interesting  change  takes  place  in  the  epithelium 


UTERINE  FIBROIDS 


m 


of  the  protruded  part.  So  long  as  the  tumour  is  contained 
within  the  cavity  of  the  uterus,  the  epitheUum  covering  it  is 
indistinguishable  from  that  lining  the  cavity  of  the  uterus. 
When  the  tumour  enters  the  vagina,  the  columnar  epithelium 
stratifies  on  the  protruded  surface,  but  that  lining  the  glandular 
recesses  remains  columnar  and  retains  its  cilia  (Fig.  91). 

3.  Subserous  fibroids. — These  arise  from  the  uterine  tissues 


g|T-ii^ir 


Fig.  91.— Microscopic  characters  of  the  ej^ithelium  covering  the  protruded  portions 
of  a  submucous  fibroid ;  it  shows  the  mutation  of  columnar  ciliated  into  stratified 
epithelium  as  a  result  of  pressure.     (Gervis.) 

subjacent  to  the  peritoneal  covering.  When  numerous  they 
rarely  attain  large  proportions.  When  the  number  is  limited 
to  three  or  four,  one  or  more  of  them  may  attain  moderate 
proportions ;  like  the  submucous  variety,  they  often  become 
pedunculated,  and  when  numerous  they  cause  the  uterus  to 
assume  a  characteristic  tuberous  appearance.  Sometimes 
as  many  as  fifteen  or  twenty  of  these  protuberances  may  be 
counted  on  a  uterus,  and  they  vary  in  size  from  a  pea  to  a 
large  walnut.  In  such  cases,  even  when  no  intramural  tu- 
mours are  present,  the  walls  of  the  uterus  are  thicker  than 
natural.     Subserous  fibroids  of  this  character  rarely  cause  any 


172  G0NNEGTIVE-TI8SUE   TUMOURS 

inconvenience,  and  are  often  found  after  death  in  individuals 
in  whom  they  have  never  j^roduced  the  least  inconvenience 
during  life,  or  in  whom  their  presence  has  not  been  even 
suspected.  The  largest  subserous  fibroid  I  have  removed 
weighed  sixteen  kilogrammes. 

In  some  rare  instances  the  endometrium  may  be  thickly 
beset  with  small  fibroids  varying  in  size  from  a  mustard-seed 
to  a  dove's  egg,  the  tumours  being  entirely  confined  to  the 
tissues  of  the  endometrium.  I  have  seen  three  examples  of 
this  variety  of  the  disease,  and  in  each  the  number  of  fibroids 
exceeded  one  hundred  ;  in  one  of  them  several  of  the  larger 
fibroids  projected  into  the  cavity  of  the  uterus,  and  by  mutual 
compression  facets  had  been  produced  on  their  surfaces,  so 
that  on  section  of  the  organ,  after  hardening,  the  cut  surfaces 
of  the  fibroids  occupying  the  uterine  cavity  resembled  in  out- 
line a  section  through  the  bones  of  the  carpus.  In  each 
instance  the  patients  suffered  from  long-continued,  profuse, 
and  exhausting  metrorrhagia. 

Latent  fibroids. — If  a  number  of  uteri  be  examined,  from 
women  between  the  twenty-fifth  and  fiftieth  years,  by  the  simple 
means  of  sectioning  them  with  a  knife,  in  a  large  proportion 
of  them  numerous  small  rounded  fibroids  resembling  knots 
in  wood  will  appear,  their  whiteness  being  in  strong  contrast 
with  the  redness  of  the  surrounding  muscle-tissue ;  these 
discrete  bodies,  in  many  instances  no  larger  than  mustard- 
seeds,  are  in  histologic  structure  identical  with  the  fully-grown 
tumours.  A  uterus  may  contain  ten  or  more  of  them  without 
the  least  distortion  of  contour  or  alteration  in  its  size.  These 
seedling  fibroids  may  never  cause  trouble,  may  never  pass 
beyond  this  stage,  and  often  calcify  in  old  age,  but  they  may 
at  any  time  grow  and  become  formidable  tumours. 

A  careful  consideration  of  the  great  frequency  of  seedling 
fibroids,  and  their  multiplicity  when  compared  with  the  num- 
ber of  fibroids  which  attain  a  size  sufficient  to  render  them 
chnically  appreciable,  makes  it  undeniable  that  a  large  pro- 
portion of  them  remain  latent.  They  may  be  compared  to 
latent  buds  in  trees  (knors)  and  plants,  on  the  ground  that 
they  may  remain  quiescent  for  a  number  of  years  and  then 
assume  active  growth  without  any  known  cause. 

Latent  fibroids  have  an  important  practical  bearing ;  it  is 


CEBVIOAL  FIBB0ID8 


173 


not  an  uncommon  experience  for  an  operator  to  dilate  the 
uterine  canal  and  abstract  two  or  more  submucous  fibroids. 
However  carefully  the  procedure  may  be  conducted,  and  how- 
ever thoroughly  the  walls  of  the  cavity  may  be  examined 
for  minute  fibroids,  no  honest  assurance  can  be  given  to  the 
patient  that  other  fibroids  will  not  grow. 

Fibroids  of  the  neck  of  the  uterus. — These  tumours  do 
not  arise  so  frequently  in  the  neck  as  in  the  body  of  the 


Fallopian  tu^he. 
Round  ligament. 


Os  uteri. 


Fig.  92.— An  intracervical  fibroid  from  a  sterile  married  woman  40  years  of  age. 
The  fundus  of  the  uterus  reached  the  level  of  the  umbilicus. 

Uterus,  but  they  are  fairly  frequent,  sometimes  attain  large 
proportions,  and  possess  peculiar  features  (Fig.  92). 

In  the  early  stages  of  growth,  cervical,  like  the  common 
forms  of  uterine,  fibroids  are  more  or  less  globular,  but  when 
they  exceed  this  size  they  tend  to  become  ovoid.  Fibroids 
may  grow  from  any  part  of  the  cervix ;  commonly  they  arise 
from  its  walls  in  such  a  way  as  to  occupy  the  cervical  canal 
(Fig.  93).     These  are  known  as  intracervical  or   submucous 


174 


CONNECTIVE-TISSUE   TUMOURS 


cervical  fibroids.  Less  frequently  they  grow  from  the  periphery 
of  the  cervix  and  do  not  invade  the  canal,  but  burrow  under 
the  peritoneum  on  the  anterior  or  the  posterior  aspect  of  the 
uterus  (Figs.  94  and  95).  These  are  known  as  subserous 
cervical  fibroids. 

The  oval  character  of  the    cervical    fibroid  is    best  dis- 
played in  the  submucous  variety,  for  as  it  grows  it  pushes 

the  body  of  the  uterus,  which  is 
perched  on  its  upper  pole,  high 
into  the  abdomen,  and  in  the 
case  of  very  large  tumours  the 
fundus  of  the  uterus  can  be 
detected  as  high  as  the  navel. 
The  topography  and  shape  of 
this  kind  of  tumour  are  best  dis- 
played when  the  parts  are  sec- 
tioned in  a  sagittal  direction. 
The  oval  shape  of  cervix  fibroids 
is  determined  by  the  osseous 
boundaries  of  the  true  pelvis. 
In  a  normal  female  pelvis  the 
pelvic  diameter  at  the  level  of 
the  middle  of  the  cervix  mea- 
sures, with  the  soft  parts  in  posi- 
tion, about  10  cm.  (4  inches); 
thus  the  lower  segment  of  a 
large  cervix  fibroid  is  a  solid 
cast  of  the  true  pelvis.  In  one  of  my  specimens  the  minor 
(transverse)  axis  of  the  tumour  measured  12 '5  cm.,  this  ex- 
cessive measurement  being  due  to  the  slow-  but  steady- 
expanding  effects  of  the  tumour  on  the  bony  walls  of  the 
pelvis.  It  is  well  to  bear  in  mind  that  the  oval  condition 
of  the  vaginal  p)ole  of  a  large  cervix  fibroid  corresponds 
with  the  shape  of  the  occiput  of  a  recently  delivered  foetus 
at  term.  The  oval  shape  is  also  attained  by  subserous 
cervical  fibroids  when  they  grow  from  the  posterior  aspect 
of  the  cervix  (Fig,  94).  This  kind  of  tumour  as  it  increases 
in  size  pushes  the  body  of  the  uterus  high  out  of  the  pelvis 
on  its  upper  pole,  but  its  relation  to  the  cervical  canal  is 
worth   some   attention.     The   intracervical   fibroid   (Fig.   93) 


Fig.  93.— Diagram  to  show  the  re- 
lation of  an  intracervical  fibroid 
to  the  cervical  canal. 


CERVICAL  FIBROIDS 


175 


uniformly  expands  the  cervix,  and  in  very  large  specimens 
its  tissues  form  a  thin  covering  to  the  tumour ;  but  a 
fibroid  of  the  posterior  aspect  of  the  cervix  elongates  it 
without  expanding  the  canal,  and  is  really  situated  between 
the  cervix  and  the  peritoneum.  This  is  a  topographical 
distinction  of  some  importance  in  connexion  with  the 
clinical  aspect  of  these  tumours. 

Fibroids  on  the  anterior  aspect  of  the  neck  of  the  uterus 
remain  more  or  less  globular,  and  do  not  distort  the  shape 
of  the  cervix  as  a  rule;  when 
of  large  dimensions  they  push 
their  way  upwards  between 
the  peritoneum  and  the  an- 
terior abdominal  wall,  and  may 
roach  as  high  as  the  umbilicus. 
It  is  a  noteworthy  feature  of 
the  cervical  fibroid  that  in 
more  than  two-thirds  of  the 
cases  the  tumour  is  solitary. 
All  varieties  of  cervix  fibroids 
are  furnished  with  a  distinct 
capsule ;  the  tumour  tissue  on 
section  presents  the  character- 
istic whorled  arrangement  of 
the  common  form  of  uterine 
fibroid,  and  is  microscopically 
identical  with  it.  Fibroids  of 
the  neck  of  the  uterus  Avhen 
they  do  not  cause  monorrhagia 
are  very  insidious,  and  rarely  give  rise  to  serious  symptoms 
until  large  enough  to  fill  the  pelvis  and  to  exert  pressure  on 
the  urethra,  the  vesical  segments  of  the  ureters,  and  the 
rectum.  In  some  cases,  especially  when  the  tumour  is  con- 
nected with  the  anterior  aspect  of  the  cervix,  there  is  direct 
pressure  on  the  bladder.  The  frequency  of  micturition, 
dysuria,  and  retention  of  urine,  which  are  such  common  con- 
comitants of  all  varieties  of  cervix  fibroids,  are  due  to  the 
bladder  being  dragged  upwards  by  the  uterus  as  this  organ  is 
pushed  out  of  the  pelvis  by  the  growing  tumour. 

In  one  example  under  my  care,  a  woman  32  years  of  age 


Fig.  94. — Diagram  of  a  fibroid  growing 
from  the  posterior  wall  of  the  cer- 
vix, showing  its  relation  to  the 
peritoneum. 


176 


GONNEGTIVE-TISSTJE    TUMOURS 


sought  relief  on  account  of  a  cervix  fibroid  which  filled  the 
vagina  and  prevented  coitus ;  it  was  successfully  enucleated 
by  the  vaginal  route. 

The  largest  intracervical  fibroid  known  to  me  is  a  specimen 
(Hunterian)  preserved  in  the  museum  of  the  Royal  College  of 
Surgeons  of  England,  It  measures  20  cm.  in  length  and 
12-5  cm.  in  width.  Unfortunately  it  is  without  history.  The 
largest  cervix  fibroid  I  have  removed  (Fig.  96)  weighed  7  lbs. 
Fibroids   of  the   mesometrium   (broad    ligament). — The 

connective  tissue  of  the  meso- 
metrium contains  a  quantity  of 
plain  muscle-tissue  which  is 
continuous  with  that  directly 
underlying  the  peritoneal  in- 
vestment of  the  uterus.  This 
muscle-tissue  is  occasionally  the 
source  of  tumours  identical  in 
structure  with  uterine  fibroids. 
In  the  early  stages  these  tu- 
mours are  ovoid,  encapsuled, 
and  often  bilateral ;  they  do  not 
cause  much  inconvenience  until 
they  attain  the  size  of  coco- 
nuts ;  even  then  they  can  be 
easily  enucleated.  They  some- 
times grow  with  great  rapidity, 
and  in  a  few  months  form 
tumours  weighing  as  much  as 
ten  kilogrammes,  and,  rising 
out  of  the  pelvis,  carry  the  uterus  and  its  appendages  with 
them. 

Some  of  the  large  globular  tumours  of  the  mesometrium 
are  spindle-celled  sarcomas  (see  p.  57).  Doran  has  described 
some  interesting  cases  and  collected  the  literature,  and  he 
points  out  that  they  have  been  observed  as  early  as  the 
twentieth  year.  The  majority  occur,  according  to  my  ob- 
servation, after  the  thirty- fifth  year.  They  are  formidable 
tumours  to  deal  with,  but  fortunately  they  enucleate  easily. 
The  largest  specimen  under  my  own  care  weighed  thirteen 
kilogrammes  and  was  successfully  enucleated. 


Fig.  95.— Diagi-am  of  a  fibroid 
growing  from  the  anterior  wall 
of  tlie  cervix,  showing  its  rela- 
tion to  the  peritoneum  as  it 
passes  from  the  anterior  wall  of 
the  uterus  to  the  bladder. 


FIBROIDS  111 

Fibroids  of  the  round  ligament  of  the  uterus.— This 
structure,  like  the  ovarian  ligament,  is  practically  a  process  of 
the  muscular  tissue  of  the  uterus,  and  tumours  in  all  respects 
like  the  fibro-myomas  of  the  uterus  arise  in  this  ligament, 


Fig.  96. — An  intracervical  fibroid  in  sagittal  section. 

not  only  in  the  segment  which  lies  in  relation  with  the 
anterior  layer  of  the  mesometrium,  but  also  in  the  terminal 
portion  which  traverses  the  inguinal  canal. 

Fibroids  of  the  ovarian  ligament. — It  is  no  uncommon 

M 


178 


CONNECTIVE -TISSUE   TUMOURS 


thing  to  find  a  fibroid  the  size  of  a  cherry  in  the  ovarian 
ligament  when  the  uterus  itself  is  occupied  by  a  crowd  of 
fibroids;  otherwise  it  is  very  rare  to  find  a  tumour  in  this 
process  of  the  uterus,  and  especially  one  large  enough  to 
be  obvious  on  clinical  examination. 

Fibroids  of  the  utero-sacral  ligament. — Occasionally  a 
fibroid  is  found  burrowing  under  the  posterior  layer  of  the 


Fig.  97.— The  cornua  of  a  bicornate  uterus  in  section  ; 
each  cornu  contains  an  interstitial  fibroid.  Re- 
moved by  subtotal  hysterectomy  from  a  woman 
aged  32  years, 

mesometrium  and  simulating  a  primary  tumour  of  this 
structure,  but  when  enucleated  it  is  found  attached  to  the 
side  of  the  cervix  near  its  junction  with  the  body  of  the 
uterus  by  a  very  narrow,  tendon-like  stalk.  It  is  probable 
that  such  a  fibroid  arises  in  the  tissue  of  the  utero-sacral 
ligament.  In  two  examples  under  my  own  care  the  fibroids 
had  a  diameter  of  12  cm. 

Fibroids  in  malformed  uteri. — Fibroids  not  only  grow 
from  uteri  of  normal  shape,  but  they  have  been  observed 
in  double  uteri  of  various  kinds  (Fig.  97),  and  even  growing 
from  the  rudimentary  cornu  of  the  so-called  "  unicorn  uterus  " 
(Doran,  Bland-Sutton,  and  Routh).  A  double  uterus  is  liable 
to  be  the  seat  of  any  kind  of  tumour  which  attacks  a  uterus 
of  normal  shape ;  but  a  fibroid  growing  in  a  malformed 
uterus  of  any  kind  is  a  rare  occurrence. 


REFERENCES  179 

Bland-Sutton,  J.,  "A  Tumour  of  the  Mesometriutn  weighing  twenty-two 
pounds."— rra?i.s.  Obstet.  Soc,  1899-1900,  xli.  298. 

Bland-Sutton,  J.,  "  On  some  Cases  illustrating  the  Surgery  of  the  Uterus." — 
Clin.  Journ.,  1901-2,  xix.  1  ("  On  Fibroids  in  a  Unicorn  Uterus,"  p.  8). 

Doran,  A.,  "  Fibroid  of  the  Broad  Ligament,  weighing  forty-four  and  a  half 
pounds  (twenty  kilogrammes),  removed  by  Enucleation ;  Eecovery. 
With  Table  and  Analysis  of  Thirty-nine  Cases."  —  Trams.  Oistet.  Soc, 
1899-1900,  xli.  173. 

Doran,  A.,  "  The  Kemoval  of  a  Fibroid  from  a  Uterus  Unicornis  in  a  Parous 
Subject."— ^rii!.  Med.  Juurn.,  1899,  p.  1389. 

Routh,  Amand,  "Fibroid of  One-Horned  Uterus." — Trans.  Oistet.  Soc,  1887-88, 
xxix.  2. 


CHAPTER    XVII 

STRUCTURE  AND  SECONDARY  CHANGES  OF 
UTERINE  FIBROIDS 

Uterine  fibroids  differ  miicli  in  texture :  some  are  as 
liard  as  cartilage,  and  a  few,  when  calcified,  resemble  porous 
stone ;  others  are  as  soft  and  succulent  as  a  ripe  orange,  and 
occasionally  some  are  like  jelly.  Between  these  extremes 
every  degree  of  hardness  or  softness  occurs ;  but  they  all 
agree  in  one  particular — namely,  in  the  possession  of  a 
well-developed  capsule,  a  structure  of  vital  importance  to 
a  fibroid,  as  its  life  depends  upon  it.  Hard  fibroids  are 
yellowish-white  on  section,  softer  specimens  resemble  the 
normal  colour  of  the  uterus.  Soft  tumours,  as  a  rule,  grow 
quickly,  and  are  very  vascular,  but  the  hardest  and  the 
gelatinous  fibroids  are  poorly  supplied  with  blood. 

It  is  by  no  means  uncommon  to  find  a  uterus  possess- 
ing many  fibroids  (twenty  or  more),  some  of  which  are  very 
hard ;  one  or  more  may  be  calcified,  others  are  of  the  same 
density  as  the  wall  of  the  uterus,  while  one  or  more  are 
soft  and  even  diffluent. 

Attention  has  already  been  drawn  to  the  fact  that  the  only 
structural  feature  fibroids  have  in  common  is  a  well-marked 
capsule,  of  fibrous  tissue,  which  completely  isolates  the 
tumour  proper  from  the  uterine  tissue.  Even  in  com- 
pletely calcified  fibroids  a  thin  capsule  can  be  demonstrated, 
and  occasionally  the  only  solid  representative  of  the  fibroid 
is  the  capsule,  the  originally  solid  parts  of  the  tumour 
having  slowly  liquefied  (Fig.  98).  Fibroids  changed  in  this 
way  are  often  referred  to  as  "  fibre- C3^stic  "  tumours.  In  some 
instances  the  capsule  of  a  fibroid  calcifies  and  encloses  the 
tumour  in  a  more  or  less  complete  shell.  Fibroids  in  this 
condition  are  dead,  and  on  section  exhibit  the  dirty  yellow 
colour  of  chamois  leather,  and  equal  it  in  toughness. 

180 


UTERINE    FIBROIDS 


181 


The  most  typical  variety  of  "  fibroid "  not  only  resembles 
the  wall  of  the  normal  uterus  in  toughness,  but  is  similar 
to  it  in  microscopic  structure,  and  consists  of  unstripecl 
muscle-tissue,  which  has  a  remarkable  tendency  to  be  arranged 
in  whorls  (Fig.  99). 

The  very   hard   fibroids    are    composed    of   tissue  which 


Fig.  98. — A  sessile  subserous  fibroid  which  had  undergone  extensive  mucoid 
degeneration.     From  a  sterile  married  woman  37  years  of  age. 

microscopically  resembles  dense  fibrous  tissue,  Avith  here  and 
there  strands  of  cells  resembling  unstriped  muscle  cells. 
This  variety  is  often  called  fibro-myomas,  and  its  mem- 
bers display  the  whorled  arrangement  in  a  very  striking 
manner.  The  fibro-myomas  are  very  liable  to  calcify.  The 
deposit  of  earthy  salts  does  not  take  place  in  an  irregular 
manner,  but  follows   the  disposition  of    the   fibres,  and  the 


182 


CONNECTIVE-TISSUE   TUMOUES 


whorled  arrangement  is  seen  when  the  sawn  surface  is 
examined  (Fig.  100).  When  incompletely  calcified  tnmom's 
are  macerated,  and  the  decayed  tissue  is  washed  away,  the  cal- 
careous matter  remains  as  a  coherent  skeleton  of  the  tumour. 
Such  changes  have  taken  place  whilst  the  tumour  remained 
in  the  living  uterus;  they  were  formerly  termed  "womb 
stones."  OccasioDally,  in  old  women  the  uterus  attempts  to 
extrude  a   calcified   fibroid;  when    the  tumour   is   large  the 


Fig.  99. — Minute  structure  of  a  young  uterine  fibroid ;  the  circular  cells  are 
spindle  cells  cut  at  right  angles.  This  figure  represents  a  complete  section 
through  the  equator  of  a  seedling  fibroid  the  size  of  a  mustard-seed. 

result,  if  left  to  the  efforts  of  nature,  is  as  a  rule  disastrous. 
The  extraction  of  such  a  tumour  by  art  is  difficult  and 
tedious.  When  "calcified  fibroids"  have  been  found  in 
coffins,  in  old  burying-grounds,  they  have  been  mistaken 
for  vesical  calculi. 


UTERINE  FIBROIDS 


183 


The  soft,  jelly-like  fibroids  are,  in  the  majority  of  cases,  due 
to  secondary  (myxomatous)  changes  in  tumours  which  were 
originally  hard.  This  is  proved  by  the  fact  that  patches  of 
softening  are  found  in  hard  tumours,  and  occasionally  fibroids 
come  to  hand  in  which  the  very  hard,  calcified,  gelatinous 
and  difiluent  tissues  co-exist.  However,  it  is  important  to 
remember  that  these  changes  do  not  always  depend  on  the 
age  of  the  tumour,  for  a  very  large  proportion  of  uterine 
fibroids  which  occur  before  the  thirtieth  year  are  myxomat- 
ous. What  is  more  important,  these  soft  (almost  liquid) 
fibroids  are  locally  malignant — that  is,  they  recur  if  enu- 
cleated,   and    this    sometimes    happens    very    quickly.     In 


Fig.  100. — Calcified  uterine  fibroid  in  section.     (3Iuseicm,  3fiddlesex  Hospital.) 


1898  I  removed  through  the  vagina  a  jelly-like  fibroid,  as 
big  as  an  orange,  from  the  uterus  of  a  woman  45  years 
of  age,  and  was  careful  to  remove  the  whole  capsule.  In 
six  months  she  returned  with  a  tumour  in  the  uterus 
occupying  the  position  of  the  original  fibroid,  but  twice  its 
size.  Hysterectomy  Avas  performed,  and  the  uterus  con- 
tained a  large  myxomatous  fibroid.  She  remains  free  from 
recurrence. 

Women  with  hard  fibroids  rarely  complain  of  them,  but 
when  the  fibroid  is  soft  like  jelly  the  health  of  the  patient 
is  markedly  impaired,  quite  apart  from  the  anaemia  due  to 
monorrhagia. 

Red  degeneration  (necrobiosis). — This  change  in  fibroids 


184  GONNEGTIVE -TISSUE    TUMOURS 

is  best  studied  in  specimens  which  are  complicated  by 
pregnane}^     It  is  considered  at  p.  199. 

Malignant  changes  in  fibroids. — It  is  believed  by  many 
that  a  sarcomatous  change  may  arise  in  uterine  fibroids.  The 
matter  has  been  carefully  considered  by  competent  men,  and 
a  critical  examination  of  the  evidence  makes  it  clear  that  in 
a  very  large  proportion  of  the  cases  described  as  "  sarcomatous 
degeneration  of  a  fibroid"  the  changes  were  due  to  septic 
infection.  In  all  future  records  published  as  evidence  in  this 
direction  there  must  be  a  careful  account  of  the  minute 
structure  of  the  tumour  by  a  competent  pathologist.  The 
great  defect  in  nearly  all  the  recorded  cases  in  which  the 
malignant  change  has  been  suspected  is  the  absence  of  any 
description  of  the  mode  of  death  where  the  patient  survived 
the  operation.  Sarcomas  are  so  prone  to  disseminate,  that 
any  patient  who  has  died  in  consequence  of  malignant 
degeneration  of  a  fibroid  would  be  expected  to  have  secondary 
nodules  in  the  lungs  at  least. 

The  most  convincing  case  which  has  come  under  my 
notice  occurred  in  a  woman  59  years  of  age :  she  died  in  the 
Middlesex  Hospital  under  the  care  of  Dr.  Finlay.  I  made 
the  post-mortem  examination.  The  uterus  contained  a 
fibroid  as  big  as  a  child's  head,  attached  to  the  fundus  of  the 
uterus :  it  was  adherent  to  and  had  penetrated  the  bladder 
and  intestine.  Secondary  nodules  were  found  at  the  base  of 
the  right  lung,  on  the  wall  of  the  left  cardiac  ventricle,  and  in 
the  left  kidney.  The  microscopic  characters  of  the  uterus 
were  those  of  a  myoma  and  a  spindle-celled  sarcoma.  The 
secondary  nodules  displayed  the  same  structure. 

Griffith  and  Williamson  have  recorded  in  detail  the  case 
of  a  woman  aged  56  who  died  in  St.  Bartholomew's  Hospital 
with  a  sarcomatous  fibroid.  The  uterus  contained  several 
fibroids,  and  secondary  nodules  were  found  in  the  lungs. 

In  many  cases  reported  as  fibroids  undergoing  malignant 
change  the  tumours  were  in  all  probability  sarcomatous  from 
the  beginning.    They  should  be  called  sarcomatous  fibroids. 

An  attempt  has  been  made  by  Piquand  to  formulate  the 
symptoms  and  diagnostic  features  of  sarcomatous  disease  of 
the  uterus.  He  attempts  to  arrange  the  disease  under  three 
headings,  thus :   sarcoma   of    the   interstitial    tissue   of    the 


UTERINE  FIBROIDS 


185 


uterus ;  sarcoma  primary  in  the  endometrium ;  and  sarcoma 
of  the  neck  of  the  uterus. 

Of  these  three  groups,  that  of  the  racemose  sarcomas  of  the 
neck  of  the  uterus  is  the  most  distinctive  and  easiest  of  recogni- 
tion, chnically  and  microscopically  (see  p.  56).  In  regard  to 
sarcoma  of  the  body  of  the  uterus  and  the  endometrium  there 
is  great  difficulty.  As  a  matter  of  fact,  there  is  every  gradation 
from  the  hard  fibroid  and  the  typical  myoma  to  the  soft, 


Fig.   101. — The  body   of  the  uterus  in   coronal  section,  showing  a   large  fibroid 
traversed  by  narrow  tortuous  canals — probably  lymph-spaces. 

diffluent  myxoma.  Among  the  softer  forms  we  meet  with  the 
spindle-cell  sarcoma  (the  recurrent  fibroid  of  older  writers), 
which  surgeons  fail  to  recognize  until  the  patient  comes  under 
observation  with  signs  of  local  recurrence.  In  this  particular 
histology  fails  us,  in  spite  of  its  triumphs. 

Fibroids  complicated  with  cancer  of  the  uterus.— This 
sinister  combination  is  discussed  in  Chap,  xxxviii. 

Lymphatics  in  fibroids. — It  is  not  uncommon,  when 
removing  large  uterine  fibroids  by  cceliotomy,  to  find  lymph- 
vessels  in  the  broad  ligaments  as  big  as  the  radial,  or  even 


186  CONNECTIVE-TISSUE  TUMOURS 

of  the  size  of  ttie  axillary  A^ein.  Occasionally  a  firm  fibroid 
will  present  on  section  numerous  irregular  tortuous  channels 
(Fig.  101).  These  are  probably  lymph-spaces.  It  has  hap- 
pened to  me  on  several  occasions,  when  operating  on  sub- 
serous fibroids,  to  find  the  tumour  adherent  to  the  great 
omentum,  and  the  arteries,  veins,  and  lymphatics  in  the 
adherent  portions  of  the  omentum  were  so  enormously 
developed  as  to  form  a  mixed  rete  mirabile  ;  the  arteries 
bemg  in  many  instances  as  big  as  radials,  the  veins  equal  to 
the  cephahc,  and  the  lymphatics  of  the  size  of  goose-quills. 
The  contrast  of  the  maroon  tint  of  the  arteries,  the  deep  blue 
of  the  veins,  and  the  light  yellow  of  the  thin-walled  lym- 
phatics formed  an  anatomical  picture  scarcely  likely  to  be 
forgotten  by  one  who  has  had  to  deal  with  such  a  condition. 

Rate  of  growth  of  fibroids. — On  this  subject  there  are 
very  few  facts  forthcoming.  In  general  terms  it  may  be 
stated  that  soft  fibroids  grow  quickly,  the  hard  ones  increase 
very  slowly;  those  fibroids  grow  most  quickly  which  soften, 
and  it  is  a  remarkable  fact  that  when  the  myxomatous 
change  is  established  in  one  of  these  tumours  it  will  often 
increase  in  size  with  astonishing  rapidity. 

The  only  observation  I  have  been  able  to  make  with  any 
accuracy  in  regard  to  the  rate  of  growth  of  fibroids  is  the 
following : — 

In  1896  I  enucleated  by  means  of  an  abdominal  incision 
from  the  uterus  of  a  woman  23  years  of  age  (I  obtained 
a  copy  of  her  birth  certificate)  a  fibroid  measuring  15  cm. 
in  its  major  and  5  cm.  in  its  minor  axis.  The  patient, 
already  mother  of  one  child,  was  delivered  of  a  healthy 
baby  eight  months  after  the  operation  :  it  was  reasonable 
to  believe  that  she  had  become  pregnant  immediately  before 
coming  into  the  hospital. 

Three  years  later  (1899)  this  woman  again  came  under 
my  care  on  account  of  a  pelvic  tumour :  this  was  watched 
for  three  months,  and  it  increased  so  much  that  it  became 
necessary  to  perform  hysterectomy.  The  uterus  contained 
twenty  tumours  varying  in  size  from  a  ripe  currant  to  a 
hen's  Qg^.  The  largest  tumour  occupied  the  cervix.  There 
were  no  signs  of  these  tumours  when  the  patient  was  sub- 
mitted to  myomectomy  in  June,  1896. 


CHAPTER  XVIII 

MODES  IN  WHICH   UTERINE  FIBROIDS 
IMPERIL  LIFE 

It  is  too  true  that  fibroids  are  the  commonest  of  all  the 
species  of  tumours  to  which  women,  whether  married  or 
single,  fruitful  or  barren,  are  liable.  It  is  also  a  fact  that 
the  uterus  may  contain  one  fibroid  or  many  and  cause  neither 
inconvenience  nor  sufferhig — indeed,  the  individual  owning 
them  is  ignorant  of  the  existence  of  tumours  in  her  womb  ; 
but  it  is  equally  true  that  they  are  often  the  source  of  much 
suffering,  and  occasionally  cause  death  in  insidious  ways, 
some  of  which  will  be  considered. 

Haemorrhage. — This  is  the  commonest  of  all  the  incon- 
veniences which  fibroids  cause,  but  it  is  confined  to  those 
which  implicate  the  endometrium.  The  bleeding  occurs 
under  two  conditions ;  most  commonly  it  takes  the  form  of 
excessive  loss  at  the  normal  menstrual  periods  (menorrhagia). 
The  most  serious  haemorrhages  are  associated  with  septic 
changes  in  the  tumour.  It  is  a  fact  of  some  importance 
that  a  small  submucous  fibroid  will  induce  such  profuse 
bleedings  at  the  menstrual  period  as  to  place  life  in  immi- 
nent peril ;  whilst  a  Jarge  interstitial  tumour,  even  though  it 
project  into  the  uterine  cavity,  scarcely  influences  the  loss. 

When  a  woman  with  a  fibroid  bleeds  excessively  between 
as  well  as  at  the  normal  menstrual  periods,  it  often  indicates 
that  the  tumour  has  become  septic. 

It  is  important  to  realize  that  oft- repeated  losses  of  blood 
continued  over  a  long  period  not  only  lead  to  profound 
anaemia,  but  also  to  grave  changes  in  the  heart-muscle,  which 
frequently  end  in  sudden  death,  as  well  as  greatly  adding  to 
the  operative  risks  when  such  individuals  submit  to  surgical 
procedures.  These  changes  have  been  carefully  described  by 
Wilson. 

187 


188  GONNEGTIVE-TISSUE   TUMOURS 

Septic  infection. — This  is,  perhaps,  the  most  serious 
complication  of  a  fibroid,  and  even  when  it  does  not  cause 
death  is  always  attended  with  dangerous  consequences.  In- 
fection of  a  fibroid  may  arise  in  a  variety  of  ways — e.g.  the 
extrusion  of  a  submucous  tumour  into  the  vagina  exposes  it 
to  injur}^,  and  micro-organisms  gain  access  to  it  through 
abrasions  in  its  capsule.  Infection  may  be  due  to  injury  from 
the  uterine  sound  or  dirty  dilators,  or  septic  changes  super- 
vening on  labour  or  miscarriage  ;  occasionally  it  is  due  to 
intestinal  gases  when  bowel  adheres  to  the  tumour.  An  in- 
fected fibroid  is  a  soft,  dark-coloured,  stinking  mass,  which 


Fig.  102. — Body  of  the  uterus  in  section  showing  two  sessile  submucous  fibroids. 
The  capsule  of  one  has  ulcerated  and  the  tumour  become  gangrenous.  The 
patient  suffered  from  excessive  and  almost  continuous  bleeding. 

bleeds  freely  when  touched.  In  the  early  stages  of  the 
infection  it  appears  on  section  oedematous,  and  exhales  a  sickly 
odour.  On  microscopic  examination  the  muscle-cells  are 
separated  by  multitudes  of  inflammatory  cells,  and  colonies 
of  pathogenic  micro-organisms  can  by  special  methods  be 
demonstrated  among  the  inflammatory  cells. 

When  a  large  fibroid  becomes  septic  it  gives  rise  to  severe 
constitutional  disturbances  (sejDticiemia),  like  gangrene  of  other 
organs,  and  will,  unless  promptly  removed,  inevitably  destroy 
Hfe  (Fig.  102). 

Small  fibroids  when  septic,  though  they  give  rise  to  serious 
trouble,  do  not  so  urgently  threaten  life,  but  they  work  great 
mischief,  for  the   infection  is   sure  to  involve   the   adjacent 


UTERINE    FIBROIDS 


189 


endometrium  (which  sometimes  sloughs)  and  creep  into  the 
Fallopian  tubes.  The  septic  matter  in  some  cases  becomes 
imprisoned  in  the  tubes  by  occlusion  of  the  coelomic  ostium  ; 
this  is  a  fortunate  event.      Occasionally  it  leaks  directly  into 


Fig.  103. — Section  of  a  uterus  from  which  a  sloughing  fibroid  had  been  removed. 
The  mucous  membrane  was  gangrenous,  and  infective  material  had  leaked  into 
the  coelom  through  the  unclosed  ostium. 

the  peritoneal  cavity  through  an  unclosed  ostium,  and  estab- 
lishes fatal  peritonitis  (Fig.  103). 

An  extruded  fibroid  often  becomes  septic,  for ,  when  the 
tumour   passes  beyond   the   external  orifice   of  the    uterus, 


190 


GONNEGTIVE-TISSUE     TUMOURS 


the  part  lying  within  the  canal  is  firmly  grasped  by  the  ute- 
rine walls  bounding  the  internal  orifice.  Should  the  tumour 
be  very  vascular,  the  venous  circulation  is  interfered  with,  and 
the  projecting  part  becomes  cedematous.  Should  the  com- 
pression continue,  the  extruded  parts  become  congested,  and 
may  even  necrose,  and  as  the  dead  tissue  is  in  a  situation 
easily  accessible  to  air,  and  consequently  to  putrefactive 
organisms,  gangrene,  with  all  its  attendant  evils,  is  the  result. 
It  is  always  necessary,  in  examining  fibroids  projecting  into 


Fig.  104:. — Partial  inversion  of  a  uterus  due  to  a  fibroid. 

the  vagina,  to  be  careful  to  distinguish  between  the  fundus 
of  an  inverted  uterus  and  a  fibroid  extruded  from  the  uterus, 
and  at  the  same  time  to  remember  that  a  submucous  fibroid 
will  occasionally  invert  the  uterus  (Fig.  104). 

Sepsis  plays  an  important  part  in  haemorrhage  associated 
with  cervical  fibroids.  Professional  opinions  on  this  matter 
are  very  divergent,  and  after  a  careful  study  I  am  able  to  state 
that  menorrhagia  and  metrorrhagia  are  only  associated  with 
the  intracervical  variety  of  fibroids  and  bear  no  relation  to 
the  size  of  the  tumour;  but  hsemorrhages  only  occur  with 
the  intracervical  fibroids  when  the  uterus  has  made  attempts 
to  extrude,  or  has  succeeded  in  extruding,  the  tumour  wholly 


UTERINE   FIBROIDS 


191 


or  partially  into  the  vagina.  The  corollary  is  obvious.  An 
extruded  or  partially  extruded  fibroid  quickly  becomes  septic, 
and  as  surely  as  this  happens  menorrhagia  and  metrorrhagia 


Myoma 


Bladdei 


Eectum. 


Urethra. 

Vagiua. 

Cervix. 
Fig.  105. — Frozen  section  of  a  pelvis  containing  an  impacted  uterine  fibroid. 

are  unfailing  consequences,  whether  the  fibroid  be  large  or 
small.  When  the  orifice"of  the  cervical  canal  remains  a  "mere 
dimple,"  menstruation  is  normal,  and  the  patient  is  usually  a 
spinster,  or,  if  married,  barren. 


192  CONNECTIVE -'TIS  SUE   TUMOURS 

Impaction  and  its  effects. — A  fibroid  is  said  to  be  im- 
pacted (or  incarcerated)  when  it  fits  the  true  pelvis  so 
tightly  that  the  tumour  cannot  rise  upwards  into  the  belly. 
All  varieties  of  fibroids  may  become  impacted,  and,  as  the 
complication  is  of  great  clinical  imj^ortance,  it  needs  detailed 
consideration. 

A  subserous  fibroid  growing  from  the  fundus  will  often 
produce  retroversion  of  the  uterus,  and  the  tumour  occupies 
the  hollow  of  the  sacrum.  As  the  tumour  grows  it  appro- 
priates the  available  pelvic  space,  and  in  due  course  exerts 
pressure  on  the  rectum  and  urethra,  interfering  with  defse- 
cation  and  micturition  (Fig.  105). 

A  solitary  intramural  fibroid  may  be  small  enough  to 
rest  in  the  true  pelvis  without  pressing  unduly  on  the  urethra 
or  ureters.  Presently  it  increases  to  such  a  point  that  the 
turgescence  which  precedes  the  menstrual  flow  will  cause  it 
to  press  the  urethra  against  the  symphysis,  and  set  up  reten- 
tion of  urine.  When  menstruation  occurs  the  turgidity  of 
the  tumour  subsides,  and  the  urethra  is  set  free.  Frequent 
recurrence  of  this  pressure  permanently  damages  the  bladder 
and  kidneys.  Very  vascular  tumours  yield  a  loud  murmur 
or  hum  on  auscultation,  a  sign  of  very  great  value  in 
differential  diagnosis.  In  many  cases  I  have  been  able  to 
demonstrate  the  existence  of  a  loud  murmur  for  a  few  days 
before  menstruation,  but  it  disappeared  with  the  flow  of 
blood,  and  remained  in  abeyance  until  a  few  days  before  the 
succeeding  period. 

The  most  insidious,  and  therefore  the  most  dangerous, 
variety  of  impaction  is  that  which  occurs  with  cervix 
fibroids.  It  has  already  been  mentioned  that  when  one  of 
these  tumours  attains  a  transverse  diameter  of  10  cm.  (4 
inches)  it  has  practically  used  up  the  spare  pelvic  space 
and  exerts  injurious  pressure  on  the  rectum,  ureters,  urethra, 
or  bladder.  Most  commonly  it  j^resses  on  the  neck  of  the 
bladder  and  causes  retention,  leading  to  frequent  and  pain- 
ful micturition.  It  is  one  of  the  most  striking  features  of 
the  cervical  fibroids  that  they  rarely  cause  bleeding  except 
when  they  extrude  from  the  mouth  of  the  uterus  and 
become  infected,  and  only  cause  inconvenience  when  they 
interfere  with  the  bladder.     Herein  lies  the  danger,  as  grave 


tJTEBINE  FiBEOIDS  193 

injury  is  often  wrought  on  the  pelvis  of  one  or  both  kidneys 
before  the  existence  of  the  tumour  is  even  so  much  as 
suspected.  It  is  an  important  fact  to  remember  that  token 
a  woman  between  35  and  45  years  of  age  seeks  relief 
because  she  suffers  from  retention  of  urine  for  a  few  clays 
'preceding  each  menstrual  'period,  it  is  cdrtibst  certain  that 
she  has  a  fibroid  in  her   uterus. 

Axial  rotation. — The  method  by  which  fibroids  under 
certain  conditions  accommodate  themselves  in  the  pelvis  is 
worth  further  note.  When  one  growing  fibroid  occupies  the 
posterior  wall  of  the  uterus  and  another  its  anterior,  so 
long  as  the  total  antero-posterior  diameter  of  the  uterus 
with  its  tumours  does  not  exceed  10  cm.  it  may  occupy  a 
normal  position.  When  this  diameter  increases,  the  uterus 
slowly  rotates,  and  the  larger  tumour  will  occupy  the  trans- 
verse diameter  of  the  pelvis.  If  growth  continues,  it  gradually 
fills  up  the  available  pelvic  space^,  and  impaction  slowly  but 
surely  ensues.  As  a  rule  the  tumour  in  the  posterior  wall  lies 
in  the  recto-vaginal  fossa,  but  occasionally  the  uterus  will  be 
so  rotated  that  the  tumour  in  the  anterior  wall  occupies  the 
space  in  the  true  pelvis,  and  that  in  the  posterior  wall  pro- 
jects into  the  hypogastrium. 

A  subserous  fibroid  with  a  long  and  slender  stalk  is  liable 
to  rotate  and  twist  its  pedicle,  a  movement  which  causes 
very  great  pain.  Some  small  calcified  pedunculated  fibroids 
may  be  so  twisted  that  they  become  detached.  A  loose  body 
of  this  kind  has  been  found  in  the  sac  of  an  inguinal  hernia. 

Intestinal  obstruction. — Uterine  fibroids  may  obstruct 
the  intestines  in  three  ways,  thus : — 

1.  A  pedunculated  subserous  fibro-myoma,  especially  if 
its  stalk  be  long  and  narrow,  may  entangle  a  loop  of  small 
intestine  and  lead  to  fatal  obstruction.  This  may  happen  with 
small  as  well  as  Avith  large  tumours.  2.  A  very  large  fibroid 
rising  high  in  the  abdomen  may  rest  upon  the  pelvic  brim 
in  such  a  way  as  to  obstruct  the  sigmoid  flexure.  3.  An 
impacted  fibroid  may  press  upon  the  rectum  and  lead  to 
obstinate  constipation  and  chronic  obstruction,  with  all  its 
inconveniences  and  evils. 

Apart  fi'om  the  various  modes  already  mentioned  in  which 
fibroids  cause  death,  they  may   destroy   life  in  unexpected 
N 


194  CONNECTIVE-TISSUE    TTJMOUTiS 

ways,  of  whidi  the  following  is  a  remarkable  and  very  unusual 
example  recorded  hy  Arnott :  A  maiden  lady  of  72  years 
was  knocked  down  by  a  large  dog  and  fell  forwards  on 
the  pavement.  She  was  seized  with  severe  pain  in  the  belly, 
and  died  in  thirty-four  hours.  At  the  autopsy  a  circular 
orifice  was  found  in  a  coil  of  ileum  which  lay  between  the 
anterior  abdominal  wall  and  a  calcified  tumour  of  the  uterus. 
There  was  extravasation  of  fseces  and  intense  peritonitis.  The 
tumour,  which  was  as  large  as  a  child's  head,  apparently 
originated  in  the  anterior  wall  of  the  uterus.  Several  small 
tumours,  also  calcified,  were  attached  by  pedicles  to  its  capsule. 
A  spinster  aged  43  fell  heavil}'  on  an  asphalted  walk, 
and  felt  severe  pain  in  the  belly.  Some  hours  later  coeli- 
otomy  was  performed,  and  a  large  pedunculated  fibroid 
weighing  6|  lb.  removed.  A  vein  on  its  surface  had  been 
lacerated  by  the  fall  and  had  bled  fi-eel}^.  She  recovered. 
(Littler.) 

Arnott,  James  M.,  "  Case  of  Large  Osseous  Tumour  of  the  Uterus  " — JHed.- 
Cldr.  Tram.,  1840,  xxiii.  199. 

Bland-Sutton,  J.,  "A  Uterus  showing  the  Effects  of  a  Gangrenous  Fibroid." — 
Tram.  Ofjstet.  Soc,  1890-91,  xxxii.  171. 

Bland-Sutton,  J.,  "Acute  Axial  Rotation  of  a  Calcified  Pibroid  of  the  Uterus. 
—Trans..  Obstet.  Soc,  1904,  xlvi.  149. 

Wilson,  T.,  "  The  Relations  of  Organic  Affections  of  the  Heart  to  Fibro-Mvoma 
of  the  Uterus." — Trans.  Obstet.  Soc,  1900,  xlii.  176. 


CHAPTER  XIX 

RELATION  OF  UTERINE  FIBROIDS  TO  MENS- 
TRUATION, CONCEPTION,  PREGNANCY, 
PUERPERY,    AND    THE    MENOPAUSE 

There  is  nothing  in  oncology  better  established  than  the  fact 
that  all  uterine  fibroids  arise  during  the  menstrual  period  of 
life.  In  Great  Britain  this  period  has  an  average  of  thirty 
years,  from  the  fifteenth  to  the  forty-fifth  year.  There  are, 
however,  few  reliable  records  of  fibroids  being  found  in  the 
uterus  before  the  twentieth  year.  Submucous  fibroids  have 
been  removed  by  coeliotomy  from  girls  of  18  years  (Scharlieb 
and  Madden).  Many  examples  have  been  observed  between 
the  twentieth  and  the  twenty-fifth  years. 

Between  25  and  35,  fibroids  are  fairly  common,  but  the 
maximum  frequency  is  attained  between  the  thirty-fifth  and 
the  forty-fifth  years. 

The  interval  between  the  twenty-fifth  and  thirty-fifth 
years  is  the  great  child-bearing  period,  with  an  average  length 
of  twelve  years.  The  menstrual  epoch  of  a  woman's  life,  in 
relation  to  pregnancy  and  fibroids,  may  be  divided  into  three 
periods,  thus : — 

1.  From  15  to  25,  in  which,  assuming  the  environment 
to  be  favourable,  a  woman  is  infinitely  more  Hable  to  con- 
ceive than  to  grow  a  fibroid. 

2.  From  25  to  35  ;  during  this  period  her  liability  to 
pregnancy  is  greater  than  in  the  preceding  period,  but  her 
liability  to  fibroids  is  also  greater. 

3.  From  35  to  45 ;  in  this  the  liability  to  conception  is 
greatly  diminished,  but  the  liabihty  to  fibroids  is  immensely 
increased. 

Not  only  is  it  true  that  fibroids  arise  during  menstrual  hfe, 
but  it  is  equally  certain  that  they  influence  menstruation,  and 
I  have  operated  on  many  cases  in  which  this  disagreeable 

195 


196 


OONNEGTWE- TISSUE   TUMOURS 


phenomenon  has  been  as  profuse  between  50  and  55,  and 
even  at  60,  as  it  was  at  20.  It  is  questionable  whether  the 
fluxes  of  blood  in  women  wdth  uterine  fibroids  after  the  age 
of  50  years  should  be  regarded  as  menstruation  in  the  proper 
acceptation  of  the  term. 


Fig.  106. — Pregnant  nterus  with  multiple  fibroids;  removed  by  operation.  After 
the  uterus  bad  been  removed,  an  incision  was  made  inthe  uterine  wall,  and,  as 
rigor  mortis  supervened  in  tbe  organ,  tbe  embryo  iu  its  amnion  was  extruded. 

If  the  conclusion  is  correct  that  the  interval  from  25 
to  35  is  the  great  child-bearing  period  of  a  woman's  life, 
it  foUows  as  a  corollary  to  the  three  deductions  in  the  pre- 
ceding section  that,  when  pregnancy  and  fibroids  co-exist, 
the  subjects  of  such  a  combination  should  be  women  past 
30,  and   these  should,  as  a  rule,  be  those   who   have   either 


FIBROIDS  AND  MENSTRUATION 


197 


married  late  in  life,  or,  if  niarried  early,  have  remained  for 
many  years  sterile.  It  is  universally  admitted  by  writers 
who  have  devoted  careful  attention  to  the  matter  that  the 
presence  in  the  uterus  of  a  submucous  or  of  a  large  interstitial 
fibroid  is  very  unfavourable  to  conception.  A  fibroid  of 
either  variety,  or  one  in  the  neck  of  the  uterus,  is  by  no 
means  a  bar  to  conception,  or  even  to  successful  pregnancy, 
but    such    a   combination  is   very   dangerous  to  the  mother 


Fig.  107. — Myomatous  gravid  uterus  in  sagittal  section.  At  the  beginning  of  the 
third  month  imjiaction  occurred ;  this  was  relieved,  and,  as  the  uterus  with  its 
tumoiu'S  was  too  long  to  lie  in  its  natural  position,  axial  rotation  occurred.  The 
antero-posterior  length  of  the  distorted  organ  was  20  cm.  Only  a  portion  of  the 
large  tumour  is  shown  in  the  figure. 

and  to  the    child.      Two    facts    may   be    stated    with  a  fair 
amount  of  accuracy  thus : 

1.  When  the  uterus  of  a  parous  woman  begins  to  grow  a 
fibroid,  she  usually  ceases  to  conceive. 

2.  When  a  woman  whose  uterus  contains  a  fibroid  con- 
ceives, this  event  is  usually  preceded  by  a  long  period  of 
unfruitful  wedlock.  A  large  subserous  fibroid  does  not  in- 
fluence conception,  but  is  occasionally  a  serious  complication 
of  pregnancy  as  well  as  of  delivery  and  puerpery. 


198 


CONNECTIVE-TISSUE   TUMOURS 


A  large  fibroid  in  the  neck  of  the  uterus  hinders 
but  does  not  prevent  conception ;  it  is,  however,  a  seri- 
ous obstacle  to  successful  delivery,  and  it  is  admitted 
by  all  practitioners  who  have  had  experience  in  mid- 
wifery that  the  most  serious  obstruction  which  arises 
in  connexion  with  uterine  fibroids  is  caused  by  a  large 
tumour  in  the  neck  of  the  uterus.    In  such  a  case  I  performed 


Fig.  108. —Uterus  in  sagittal  section;  its  neck  is  occupied  by  a  large  intracervical 
fibroid.  There  is  also  a  submucous  fibroid.  (From  a  barren  woman  aged  41, 
who  had  been  married  many  years.) 

total  hysterectomy  with  success  after  labour  had  begun 
(Fig.  110).     Rutherford  Morison  has  had  a  similar  experience. 

Inimicality  of  pregnancy  and  uterine  fibroids. — The 
banefiilness  or  harmfulness  of  the  association  of  pregnancy  is 
of  three  kinds : 

1.  Obstructive. — The  harm  which  may  arise  from  the 
obstruction  offered  by  a  fibroid  to  a  gravid  uterus  sometimes 
occurs  early  in  the  pregnancy  because  it  may  lead  to  impac- 
tion and  even  slow  torsion  of  the  uterus.  If  the  fibroid  be 
pedunculated    the    upward   movement    of  the    uterus   may 


FIBROIDS  AND  PBEGNANCY 


]99 


cause  it  to  rotate  and  twist  the  pedicle ;  occasionally  it  will 
be  incarcerated  by  the  uterus. 

2.  Septic  infection. — -An  interstitial  or  a  submucous  fibroid 
may  be  infected  from  careless  attention  to  antiseptic  details 
following  miscarriage  or    delivery  at  term :  many  puerperal 


Fig.  109. — Pregnant  uterus  clefoiined  by  fibroids ;  the  largest  grew  in  the  neck  of 

the  uterus. 


women  have  lost  their  lives  from  this  cause.  Occasionally  a 
submucous  fibroid  may  be  extruded  into  the  vagina  during 
delivery,  but  this  is  rare.  A  subserous  fibroid  may  become 
cedematous,  and  when  the  uterus  expels  the  foetus  the  tumour 
may  become  septic  and  set  up  peritonitis,  which  may  destroy 
the  patient  or  lead  to  the  formation  of  dangerous  adhesions. 
3.  Degeneration    of  the  fibroid. — This    is    an   insidious 


200 


GONNEGTIVE-TISSTIE   TUMOURS 


danger,  and   one  which  has  not  been   fully  appreciated  by 
obstetricians,  for  it  is  a  condition  often  associated  with  preg- 


Fig.  110. — Gravid  uterus  in  sagittal  section.  The  patient  miscarried  at  the  seventh 
month,  and  the  arm  presented.  Delivery  heing  impossible  on  account  of  a  large 
cervical  fibroid,  the  uterus  with  its  cervix  was  removed.  The  cedema  of  the 
presenting  arm  is  well  shown.     {Museum  of  the  RoyaJ  CoUetje  of  Surt/eons.) 

nancy  apart  from  septic  infection,  or  from  mechanical  injury 
which  the  tumour  may  receive  in  the  course  of  the  gradual 


FIBROIDS  AND  PREGNANCY 


201 


enlargement  of  the  uterus,  or  during  its  sudden  diminution 
after  delivery.  Moreover,  the  change  which  pregnancy 
induces  in  fibroids  has  interested  me  for  many  years,  and 
I  have  been  able  to  collect  a  large  number  of  facts  from 
personal  observation. 


rig.  111.— Gravid  uterus  deformed  by  fibroids  which  were  soft  and  red,  while  one 
was  difluent.  Eenioved  from  a  woman  aged  28  on  account  of  pain,  impaction, 
and  rotation  of  the  uterus.     The  arrow  lies  in  the  cervical  canal. 


The  usual  colour  of  a  uterine  fibroid  is  pale  yellow;  in 
many  degenerating  and  necrotic  fibroids  this  colour  deepens. 
In  the  course  of  pregnancy  a  fibroid,  especially  one  of  the 
interstitial  kind,  assumes  a  deep-red  or  mahogany  tint.  In 
the  early  stages  the  tumour  exhibits  the  colour  in  streaks, 
but  as  the  pregnancy  advances  it  permeates  the  whole  tumour. 
Occasionally,   even     in    the    mid-period    of  pregnancy,   this 


202  GONNEGTIVE-TISSUE   TUMOURS 

necrotic  change  may  be  so  extreme  that    the  central  part  of 
the  tumour  is  reduced  to  a  red  pulp. 

In  1903  Fairbairn  wrote  an  excellent  j)aper  on  this 
necrotic  change  in  fibroids,  and  it  is  now  becoming  familiar 
as  the  "red  degeneration."  Until  Fairbairn  began  to  accu- 
mulate the  material  for  this  paper  I  held  the  opinion  that 
this  change    was    only  seen  in  association  with   pregnancy, 


Fig.  112. — Uterus  distorted  with,  fibroids,  and  containing  a  foetus  of  four  months' 
development.     (From  a  woman  aged  42  years.) 

but  he  soon  convinced  me  that  it  occurred  in-  sjDinsters,  and 
I  have  myself  since  seen  well-marked  examples  in  women 
who  have  never  been  pregnant.  At  the  same  time  it  must 
be  stated  that  the  largest  number,  the  best  marked,  so  far 
as  colour  goes,  and  the  most  extreme  examples  of  this  red 
degeneration  occur  in  association  with  j)regnancy. 

In  the  earl}'-  cases  which  came  under  my  notice,  the 
redness  of  the  cut  surface  of  these  tumours  so  strikingly 
resembled  beefsteak  that  it  suggested  to  me,  and  appears  to 


BED  DEQENEBATION  203 

have  done  so  to  other  observers,  that  the  change  in  colour 
might  be  due  to  an  increase  in  the  muscle-fibres  in  conse- 
quence of  the  physiological  enlargement  of  the  uterus.  The 
microscope,  however,  dispelled  this  illusion,  showing,  the 
colouring  material  to  be  blood-pigment  diffused  through 
the  necrotic  tissue  of  the  tumour.  Murray  ascribes  the 
redness  af  these  fibroids  to  necrobiosis  accompanied  by 
haemolysis  and  diffusion  of  the  blood-pigment. 

Smith  and  Shaw  succeeded  in  finding  micro-organisms 
in  these  red  degenerate  fibroids.  They  are  not  present  in 
all,  Hastings  isolated  and  obtained  in  pure  culture  Staphy- 
lococcus pyogenes  aureus  from  one  of  my  specimens,  but  as 
a  rule  these  softened  tumours  are  sterile. 

This  red  degeneration  is  of  interest  outside  the  pathological 
laboratory  :  it  is  of  clinical  importance,  because  fibroids  which 
are  undergoing  this  peculiar  change  are  often  painful  and  ex- 
tremely tender.     This  tenderness  is  a  valuable  diagnostic  sign. 

Kefiections  on  the  complications  resulting  from  the  pre- 
sence of  fibroids  in  the  walls  of  a  pregnant  uterus  make  it 
obvious  to  any  thoughtful  practitioner  that  this  may  be 
described  as  a  malicious  combination. 

Fibroids  and  tubal  pregnancy. — This  is  a  rare  com- 
bination, but  it  occurs,  and  the  co-existence  of  a  gravid 
tube  and  large  or  moderate-sized  fibroids  in  the  uterus 
gives  rise  to  unusual  difficulty  in  diagnosis.  How  great 
this  may  be  is  set  forth  in  a  case  described  with  great 
care  and  detail  by  Cullingworth  in  1898.  The  literature 
of  this  unfortunate  combination  has  been  collected  by  Frank 
E.  Taylor.     It  is  very  scanty. 

Fibroids  and  the  menopause. — It  was  formerly  taught 
and  believed  that  uterine  fibroids  cease  to  be  troublesome 
with  the  cessation  of  menstruation.  It  is  quite  certain  that 
this  opinion  requires  reconsideration.  Uterine  fibroids  are 
peculiar  in  their  age-distribution,  for,  as  has  already  been 
mentioned,  they  only  arise  during  menstrual  life  (15  to  45), 
but  they  stand  absolutely  alone  among  tumours  in  possessing 
another  remarkable  character :  as  a  rule,  they  cease  to  grow 
after  the  menopause,  and  in  some  instances  they  undergo  a 
marked  diminution  in  size.  To-day  no  gyna3Cologist  seriously 
believes  that  uterine  fibroids  disappear. 


204  G0NNEGTIVE-TI88UE   TUMOURS 

Though  fibroids,  as  a  rule,  cease  to  grow  after  the  meno- 
pause, it  must  not  be  forgotten  that  they  soiQietimes  take  on 
unusually  rapid  growth  at  this  period  ;  and,  apart  from  this, 
they  ■  are  often  sources  of  great  peril  to  life  by  co-existing 
with  other  serious  diseases  of  the  uterus,  tubes,  and  ovaries ; 
while  the  very  fact  that  they  are  apt  to  diminish  in  size  is 
occasionally  a  source  of  danger.  Apart,  however,  from  these 
considerations,  the  fibroids  are  themselves  sources  of  trouble 
on  account  of  the  degenerate  and  septic  changes  to  which  they 
are  liable.  It  is  also  very  essential  to  bear  in  mind  that  the 
existence  of  a  fibroid  in  the  uterus  has  in  a  very  large  propor- 
tion of  cases  a  malicious  influence  in  delaying  the  menopause. 
The  uterus  has  often  been  removed  from  patients  between 
50  and  60  years  of  age  in  whom  monthly  fluxes  of  blood 
were  as  regular  as,  but  much  more  profuse  than,  in  women 
of  20  years.  On  the  other  hand,  occasionally  a  woman  may 
have  her  menopause  at  the  forty-second  or  forty-fifth  year, 
though  a  large  fibroid  is  connected  with  the  uterus. 

The  fact  that  a  fibroid  may  shrink  after  the  menopause  is 
in  itself  frequently  a  source  of  danger,  especially  when  it  is 
pedunculated,  for  the  tumour  may  be  so  big  that  its  size 
prevents  it  from  tumbling  into  the  pelvis,  but  after  the 
shrinking  consequent  on  the  menopause  such  a  fibroid  may 
fall  into  the  true  pelvis  and  become  impacted.  It  is  an 
uncommon  complication,  but  it  happens. 

The  most  frequent  and  most  dangerous  alterations  in 
fibroids  after  the  menopause  are  necrotic  and  septic  changes. 
During  menstrual  life  fibroids  generally  enjoy  an  abundant 
blood-supply ;  in  some  instances  they  are  almost  as  vascular 
as  naevi.  On  the  occurrence  of  the  menopause,  the  cessation 
of  the  menstruation  is  accompanied  by  a  remarkable  abate- 
ment in  the  blood-supply^  and  not  only  does  the  tumour  cease 
to  grow,  or  even  shrinks,  but  the  very  fact  that  its  nutritive 
irrigation,  so  to  speak,  is  arrested  leads  to  degenerative 
changes,  and  the  fibroid  becomes  in  many  instances  a  dead, 
sequestered  body,  which  may  calcify.  So  long  as  septic 
organisms  are  denied  access  it  will  remain  inert ;  but  when, 
from  various  causes,  putrefactive  organisms  gain  access  to 
it,  the  results  are  often  dire  in  the  extreme. 

It  is  far  easier  to  prove  that  putrefactive  organisms  obtain 


FIBROIDS  AND   THE  MENOPAUSE  205 

access  to  dead  or  dying  fibroids  than  to  tell  how  they  get  to 
them.  There  is,  however,  one  mode  of  access  which  is  un- 
deniable. The  fibroids  which  give  rise  to  most  trouble  after 
the  menopause  are  those  of  the  submucous  variety,  and  there 
seems  a  strong  tendency,  v^^hen  the  uterus  passes  into  its 
resting  stage  and  the  fibroid  is  shrinking  and  dying,  for  the 
organ  to  attempt  the  extrusion  of  the  tumour.  A  careful 
study  of  the  cases  which  have  come  under  my  observation 
teaches  me  that  a  fair  proportion  of  troublesome  post-meno- 
pause fibroids  have  undergone  partial  extrusion,  or  the  mouth 
of  the  womb  being  widely  dilated  facilitates  the  ingress  of 
pathogenic  micro-organisms. 

A  study  of  the  post-menopause  behaviour  of  uterine 
fibroids  and  the  perils  they  entail  indicates  in  no  uncertain 
manner  that  even  in  obsolescence  they  are  often  mischievous 
and  insidiously  lethal.  The  relation  of  submucous  fibroids 
to  cancer  of  the  uterus  is  discussed  in  Chap,  xxxviii. 

Bland-Sutton,  J.,  "  Essays  on  Hysterectomy,"  London,  1905. 

CuUingworth,  C.  J.,  "Early  Ectopic  Gestation  (?  Tubo-Uterine)  complicated 
by  Fibro-Myoma  of  the  Uterus."-— Trans.  Obstet.  Soe.,  1898,  xl. 

Fairbairn,  J.  S.,  "  A  Contribution  to  the  Study  of  One  of  the  Varieties  of 
Necrotic  Change  in  Fibro-Myomata  of  the  Uterus." — Jotirn.  of  Oistet.  and 
Gyn.  of  Brit.  Emp.,  1903,  iv.  119. 

Morison,  Rutherford,  Nortliumierland  and  Durham  Med.  Jonrn.,  July  190J:. 

Murray,  H.  L.,  "The    Haeniolytic   Lipoids   of    Degenerating   Fibroids,   with 

special  reference  to  Eed  Degeneration." — Journ.  of  Obstet.  and  Gyn.,  1910, 

xvii.  534. 

Smith,  J.  L.,  and  Shaw,  W.  F.,  "  Pathology  of  the  Eed  Degeneration  of 
'¥ihxo\ds."— Lancet,  1909,  i.  242. 

Taylor,  F.  E.,  "Extra-Uterine  Gestation  associated  with  Fibro-Myomata." — 
Joimi.  of  Obstet.  and  Gyn.  of  Brit.  Emp.,  1906,  ix.  412. 


CHAPTER  XX 

CLINICAL   CHARACTERS   AND  TREATMENT 
OF   UTERINE   FIBROIDS 

Clinical  characters. — Uterine  fibroids,  though  exceedingly 
common,  are  unknown  before  puberty,  and  rarely  attract 
attention  before  the  twentieth  year;  they  are  most  common 
between  the  thirtieth  and  fiftieth  years.  In  a  large  propor- 
tion of  patients  the  earliest  indication  of  the  presence  of  a 
fibroid  in  the  uterus  is  excessive  menstruation  (monorrhagia); 
this  is  often  the  only  symptom  which  leads  the  patient  to  seek 
advice,  and  on  examination  a  large  pelvic  tumour  may  be 
detected.  In  many  cases  there  is  no  obvious  enlargement  of 
the  uterus;  the  fibroid,  though  big  enough  to  cause  severe 
bleeding,  is  not  large  enough  to  be  detected  until  the  cavity  of 
the  uterus  is  explored  through  a  dilated  cervical  canal.  In 
many  instances,  when  the  patient  seeks  advice  the  tumour  is 
actually  presenting  at  the  mouth  of  the  womb. 

Fibroids  large  enough  to  rise  out  of  the  pelvis  usually  oc- 
cupy the  hypogastrium,  but  when  stalked  they  may  lie  laterally 
and  simulate  ovarian  tumours.  On  palpation  fibroids  may  be 
smooth,  but  when  their  surfaces  are  tuberous  it  is  a  valuable 
sign.  Auscultation  sometimes  furnishes  useful  evidence,  for 
soft,  rapidly  growing  fibroids  often  yield  a  loud  hum  syn- 
chronous with  the  pulse,  like  the  murmur  heard  during 
pregnancy.  This  venous  hum  is  most  frequently  detected 
shortly  before  the  onset  of  a  menstrual  period. 

On  vaginal  examination,  the  tumour  may  be  found  closely 
associated,  and  often  incorporated,  with  the  uterus.  When 
the  tumour  occupies  the  cervix,  the  whole  organ  feels  like 
a  globular  body,  and  the  mouth  of  the  womb  is  indicated 
by  a  mere  dimple.  The  diagnosis  of  a  fibroid  in  the  uterus 
is  often  rendered  difiicult  by  comj)lications  such  as  pregnancy, 
uterine,  tubal,  or  even  cornual;  the  co-existence  of  ovarian 

206 


TREATMENT  OF    UTERINE  FIBROIDS'  207 

cysts  and  solid  tumours;  tubal  conditions  such  as  hydro- 
salpinx and  pyosalpinx  and  primary  cancer  of  the  Fallopian 
tube ;  tumours  of  the  pelvic  bones  and  connective  tissue. 

When  a  woman  has  a  tumour  suspected  to  be  a  fibroid, 
and  there  is  reason  to  believe  that  it  is  rapidly  increasing, 
it  is  worth  while  to  remember — 

1.  That  she  may  have  conceived,  so  that  the  enlarge- 

ment is  due  to  the  progress  of  the  pregnancy. 

2.  The  tumour  may  have  become  septic,  or  secondary 

changes  'may  have  led  to  the  formation  of  cyst- 
like spaces. 

3.  The  diagnosis  may  he  erroneous,  and  the  suspected 

fibroid  may  be  really  an  ovarian  tumour. 

4.  Ovarian  tumours  and  uterine  fibroids  often  co-exist. 

5.  An  over-distended   bladder  has  many  times  been 

mistaken  for  a  rapidly  growing  pelvic  tumour. 

6.  Hydrosalpinx,  pyosalpinx,  primary  cancer  of  the 

tube,  and  even  tubal  pregnancy  sometimes  com- 
plicate fibroids. 

Even  this  list  does  not  exhaust  the  possibilities,  for  a 
myomatous  uterus  may  become  impacted  in  consequence  of 
conception,  and,  when  the  impaction  is  relieved,  axial  rota- 
tion may  occur. 

Treatment. — All  attempts  to  cure  fibroids  by  drugs  or 
by  means  of  electricity  have  been  conspicuous  failures,  so 
that  patients  whose  lives  and  usefulness  are  threatened  by 
these  tumours  are  obliged  to  seek  the  aid  of  surgery. 

It  is  true  that  fibroids  often  occupy  the  uterus  for  years 
and  cause  no  trouble,  but  many  give  rise  to  severe  bleeding, 
and  place  life  in  great  jeopardy.  Kecurrent  bleeding  is  the 
most  common  condition  which  leads  women  with  fibroids  to 
seek  medical  advice.  Pelvic  pain,  due  to  pressure  of  the 
tumour  on  the  urethra,  bladder,  or  bowel,  is  common,  and 
inimical  to  health.  Inflammation  (infection)  and  gangrene 
are  dangerous  conditions.  Fibroids  complicated  with  tubal 
and  ovarian  disease  demand  careful  attention.  The  chief 
indications  for  surgical  interference  may  be  summarized 
thus : — 

1.  A   stalked  tumour   protruding  at    the   mouth   of   the 


208  aONNECTIVE-TISSUE   TUMOURS 

womb  is  readily  detactied  by  seizing  it  with  a  volsella  and 
twisting  the  stalk ;  or  the  pedicle  may  be  divided  by 
scissors. 

2.  The  presence  ot  a  submucous  fibroid  is  often  con- 
jectural ;  then  the  cervical  canal  is  dilated  and  the  interior 
of  the  uterus  explored  with  the  finger.  Small  fibroids  thus 
discovered  are  easily  removed.  Larger  tumours  require 
enucleation. 

3.  Submucous  fibroids  with  a  diameter  exceeding  5  to 
6  centimetres  usually  require  removal  of  the  uterus  (hyster- 
ectomy). 

There  is  a  consensus  of  opinion  among  surgeons  and 
gynaecologists  that  hysterectomy  for  fibroids  may  be  recom- 
mended in  the  following  circumstances : — 

i.  When  the  fibroids  cause  j^rofuse  and  long-continuing 

menorrhagia. 
iL  When  the  fibroid  is  septic  and  gangrenous. 
iii.  Impacted    and   irreducible  fibroids   causing   pain   and 

retention  of  urine, 
iv.  Fibroids  which  are  growing  rapidly  and  those  which 

are  degenerate  and  softened  (cystic). 
v.  Cervix  fibroids  too  large  to  permit  of  removal  b}^  the 

vagina, 
vi.  Fibroids  complicating  pregnancy,  delivery,  and  puer- 

pery  under  certain  conditions. 
It  is  admitted  by  most  writers  that  the  ideal  method  of 
dealing  with  fibroids  requiring  removal  by  coeliotomy  is  to 
remove  them  either  by  ligature  or  by  enucleation,  and  in 
certain  circumstances  b}?-  actually  opening  the  uterine  cavity, 
extracting  the  tumour,  and  then  suturing  the  incision  as  after 
a  Csesarean  section,  an  operation  to  which  I  applied  the  term 
hysterotomy.  In  actual  practice  this  ideal  operation  of  re- 
moving the  tumours  and  leaving  the  uterus  and  ovaries 
intact  can  only  be  carried  out  in  a  small  proportion  of  cases, 
probably  in  less  than  10  per  cent.,  and  it  is  fair  to  state  that 
enucleation  and  hysterotomy  are  often  more  troublesome  and 
serious  operations  than  hysterectomy;  also  the  preservation 
of  the  uterus  is  not  always  an  advantage  to  the  patient. 

When  a  woman  is  submitted  to  hysterectomy  for  fibroids 
we  can  assure  her  that  the  tumours  will  not  recur,  but  after 


TREATMENT  OF   UTERINE  FIBROIDS  209 

a  myomectomy  or  an  enucleation  performed  during  the  pro- 
ductive period  of  life  we  cannot  give  her  this  assurance, 
for  she  may  have  in  her  uterus  many  "  seedlings/'  or  what 
I  prefer  to  call  "latent  fibroids,"  and  one  or  several  of  these 
may  grow  into  formidable  tumours. 

In  the  case  of  a  young  woman  contemplating  matri- 
mony, or  a  married  woman  anxious  for  offspring,  myomec- 
tomy is  a  justifiable  operation.  Experience,  however,  teaches 
this  stern  lesson :  After  the  enucleation  of  a  fibroid  in  the 
procreative  period  of  life  a  woman  is  more  likely  to  groiu 
more  fibroids  in  her  ivomb  than  to  conceive  successfully. 

Another  legitimate  class  of  case  in  which  myomectomy 
is  a  very  safe  undertaking  is  in  patients  at  or  after  the 
menopause,  where  a  stalked  fibroid  gives  trouble  by  twist- 
ing its  pedicle,  or  by  shrinking  to  such  a  size  that  it  falls 
into  the  true  pelvis  and  becomes  impacted  ;  or,  more  rarely, 
where  the  pedicle  entangles  a  loop  of  small  intestine  and 
obstructs  it. 

There  are  two  methods  of  removing  the  uterus  in  the 
radical  treatment  of  fibroids,  namely,  vaginal  hysterectomy 
and  abdominal  hj^sterectomy. 

Vaginal  hysterectomy  is  only  applicable  when  the  tumour 
is  small  or  septic. 

There  are  two  methods  of  removing  the  uterus  by  the 
abdominal  route  :  one  known  as  subtotal  hysterectomy,  in 
which  the  body  with  a  variable  portion  of  its  neck  is  re- 
moved ;  and  total  hysterectomy,  in  which  the  body  and  neck 
of  the  uterus  are  completely  removed. 

Subtotal  hysterectomy  is  a  simpler  operation  than  re- 
moval of  the  whole  uterus.  When  carefully  performed, 
within  a  few  weeks  of  the  operation  the  stump  is  movable, 
and  the  vaginal  vault  free  and  undamaged,  and  the  condi- 
tion of  the  parts  is  such  that  by  digital  examination  or 
inspection  it  would  be  difficult  to  determine  that  the  patient 
had  lost  her  uterus.  The  disadvantage  uro-ed  ag'ainst  this 
method  is  the  liability  of  the  stump  to  be  attacked  by 
cancer.  A  critical  examination  of  the  reported  cases  shows 
that  in  some  of  them  an  unsuspected  cancer  existed  at  the 
time  of  the  primary  operation   (Chap,   xxxviii.). 

Total  hysterectomy  is  a  severe  procedure,  and  attended 


210  CONNECTIVE-TISSUE   TUMOURS 

often  with  more  shock  than  the  subtotal  operation  ;  it  is  also 
attended  with  risk  of  injury  to  the  vesical  segments  of  the 
ureters. 

Experience  teaches  that  subtotal  hj^sterectomy  in  spinsters 
or  barren  married  women,  when  the  uterus  has  a  long  nar- 
row  neck  and  an  undilated  cervical  canal,  is  as  safe  as  any 
major  operation  in  surger}^. 

Total  hysterectomy  should,  as  a  rule,  be  reserved  for 
those  who  have  had  children,  and  in  whom  the  cervical 
canal  is  patulous,  perhaps  septic,  and  in  many  cases  large 
and  hard,  or  large  and  spong}^  If  there  be  the  least  sus- 
picion of  malignancy  associated  with  the  tumour,  then  com- 
plete removal  of  the  cervix  with  the  uterus  is  imj)erative. 

Careful  observations  have  been  made  on  women  who  have 
submitted  to  hysterectomy  for  fibroids,  and  they  prove  that 
the  operation  is  followed  by  a  remarkable  improvement  in 
the  general  health  of  the  patients.  Since  the  introduction 
of  subtotal  hysterectomy  for  troublesome  fibroids  the  risks  of 
the  operation  have  greatly  diminished.  In  some  hospitals  in 
London  the  mortality  has  fallen  to  less  than  2  per  cent. 

Bland-Sutton,   J.,   "The   Position  of  Abdoraiual  Hysterectomy  in    London," 
1910. 


From  the  tooth- 
follicle. 


GROUP  IL    TUMOUR-DISEASES  OF  TEETH 

CHAPTER  XXI 
ODONTOMAS  AND   DENTAL   CYSTS 

An  odontoma  is  a  tumour  composed  of  dental  tissues  in 
varying  proportions  and  different  degrees  of  development, 
arising  from  teeth-germs,  or  from  teeth  still  in  the  process 
of  growth. 

The  species  of  this  genus  are  determined  according  to 
the  part  of  the  tooth-germ  concerned  in  their  formation. 

1.  Epithelial  odontoma :  from  the  enamel-organ. 

2.  FoUicuiar  odontoma 

3.  Fibrous  odontoma 

4.  Cementoma 

5.  Compound  follicular  odontoma 

6.  Radicular  odontoma:  from  the  papilla. 

7.  Composite  odontoma :  from  the  whole  germ. 

1.  Epithelial  odontomas. — These  tumours  occur,  as  a 
rule,  in  the  mandible,  but  they  have  been  observed  in  the 
maxilla.  They  have  a  fairly  firm  capsule,  and  in  section 
display  a  congeries  of  cysts  of  various  shapes  and  sizes ;  but 
the  ioculi  rarely  exceed  2  cm.  in  diameter.  The  cysts  are 
separated  by  thin  fibrous  septa,  sometimes  ossified.  The 
cavities  contain  brown  mucoid  fluid.  The  growing  portions 
of  the  tumour  have  a  reddish  tint  (Fig.  113). 

Histologically,  an  epithelial  odontoma  consists  of  branch- 
ing and  anastomosing  columns  of  epithelium,  portions  of  which 
form  alveoli  (Fig.  114).  The  cells  occupying  the  alveoli 
vary ;  the  outer  layer  may  be  columnar,  whilst  the  central 
cells  degenerate  and  give  rise  to  tissue  resembling  the  stel- 
late reticulum  of  an  enamel-organ. 

211 


212 


ODONTOMAS 


These  tumours  have  been  investigated  by  Eve  (who  gave 
them  the  name  of  multilocular  cystic  epithehal  tumours)  and 
by  Falckson  and  Bryck.  Some  of  the  tumours,  as  these 
observers  think,  may  arise  in  persistent  vestiges  of  enamel- 
organs. 

A  careful  re-examination  of  a  few  of  the  specimens 
described  as  multilocular  cystic  epithelial  tumours  of  the 
jaws,  and  a  study  of  the  descriptions  of  others,  especially 
those  occurring  in  individuals  past  middle  life,  have  satisfied 
me  that  many  of  them  were  endotheUomas  :  some  of  the 
most  typical  examples  of  these  tumours  arise  m  the  gums. 
Endotheliomas   present  such   peculiar   characters,  structural 


Fig.  113. — Epithelial  odontome.     (jVat.  size.) 


and  clinical,  that  they  need  a  group  to  themselves.  They  are 
dealt  with  in  Chap.  XL.  (p.  405). 

This  view  of  the  matter  is  confirmed  by  the  fact  that 
some  of  these  cystic  tumours  of  the  jaw  supposed  to  arise 
in  belated  rudiments,  or  vestiges,  of  enamel-organs  display 
malignancy,  inasmuch  as  they  recur  after  removal.  Moreover, 
these  tumours  occur  in  individuals  at,  or  after,  mid-life, 
whereas  if  they  arise  in  epithelial  vestiges  of  the  enamel- 
organ  they  ought,  theoretically,  to  be  met  with  in  the  young, 
which  is  not  the  case.  A  careful  reperusal  of  the  clinical 
histories  of  the  cases  collected  by  Heath  convinces  me  that 
in  the  majority  of  instances  these  tumours  arise  in  con- 
nexion with  the  mucous  membrane  of  the  jaws. 

2.  Follicular  odontomas. — This  species  comprises  those 
swellings  often  called  dentigerous  cysts,  a  term  which  has 
come  to  be  used  so  very  loosely  that  it  should  be  discarded 


FOLLIGULAR   ODONTOMAS 


213 


in  the  necessity  for  precision.  Follicular  odontomes  arise 
commonly  in  connexion  with  teeth  of  the  permanent  set, 
and  especially  with  the  molars  ;  sometimes  they  attain 
large  dimensions,  and  produce  great  deformity,  especially 
when  they  arise  in  the  upper  jaws  and  happen  to  be  bilateral. 
They  occur  in  connexion  with  supernumerary  teeth. 

The  tumour  consists  of  a  wall  of  varying  thickness,  which 
represents  an  expanded  tooth-follicle ;  in  some  cases  it  is  thin 
and  crepitant,  in  others  it  may  be  1  cm.  thick.  The  cavity  of 
the  cyst  usually  contains  viscid  fluid  and  the  crown  or  the 
root  of  an  imperfectly  developed  tooth ;  occasionally  the  tooth 


Fig.  114. — Microscopical  characters  of  an  epithelial  odontome. 

is  loose  in  the  follicle,  sometimes  inverted,  and  often  its  root 
is  truncated  (Figs.  115  and  116);  exceptionally  the  tooth  is 
absent,  or  represented  by  an  ill-shaped  denticle.  The  walls  of 
the  cyst  usually  contain  calcific  or  osseous  matter;  the  amount 
varies  considerably.  Some  observers  have  noted  the  presence 
of  an  epithelial  lining  to  the  inner  walls  of  follicular  odon- 
tomas :  it  is  a  point  which  requires  further  elucidation.  In 
two  recent  specimens  I  failed  to  find  an  epithelial  lining. 

These  tumours  are  not  unknown  in  other  mammals;  I 
have  seen  them  in  sheep,  pigs,  and  porcupines.  In  sheep  they 
are  common,  and  generally  affect  the  incisors,  and  are  thus 
limited  to  the  mandible :  as  a  rule  they  are  bilateral. 

The  amount  of  fluid  in  a  follicular  odontoma  varies,  and 
the  size  of  the  tumour  depends  in  the  main  upon  this.  Occa- 
sionally the  fluid  may  measure  as  much  as  two  ounces,  and 


214 


ODONTOMAS 


this  may  lead  to  the  wide  separation  of  the  inner  and  outer 
plates  of  the  body  of  the  mandible,  and  the  odontoma  may 
occupy  the  whole  length  of  the  bone.    (Fearn's  case,  preserved 


Fig.  115. — Follicular  odontomas  from  the  mandible. 

in  the  museum  of  the  Royal  College  of  Surgeons,  is  a  good 
example  of  this  condition.) 

Hopewell  Smith  found  that  a  tooth  from  a  follicular 
odontome  had  no  Nasmyth's  membrane,  and  suggests  that 
the  fluid  within  these  tumours  is  probably  formed  from  the 
degeneration  and  liquefaction  of  the  stellate  reticulum. 


Fig.  116.— Follicular  odon- 
tome from  the  right  half 
of  a  mandible,  removed 
from  a  boy  aged  14 
years,  by  Wormald,  1850. 
{Museum  of  the  Royal  Col- 
lege of  Surgeons.) 


Fig.  117. — Fibrous  odontome  from  a  goat. 

{Nat.  size.) 


Tomes  has  suggested  that  this  species  of  odontome  is 
probably  due  to  the  excessive  formation  around  a  retained 
tooth,  between  it  and  the  wall  of  the  follicle,  of  a  fluid  which 


FIBROUS  ODONTOMAS  215 

is  normally  present  after  the  complete  development  of  a 
tooth.  Many  teeth  are  retained  without  cysts  forming  around 
them,  so  that  something  beyond  mere  retention  of  a  tooth 
is  necessary  for  the  production  of  a  follicular  odontoma 

3.  Fibrous  odontomas. — In  a  developing  tooth,  a  portion 
of  the  connective  tissue  in  which  it  is  embedded  is  found  to 
be  denser  and  more  vascular  than  the  rest ;  it  also  presents  a 
fibrillar  arrangement.  This  condensed  tissue  is  known  as  the 
tooth-sac,  and  when  fully  developed  presents  an  outer  firm 
wall  and  an  inner  looser  layer  of  tissue.  At  the  root  of  the 
tooth  the  follicle-wall  blends  with  the  dentine  papilla,  and  is 
indistinguishable  from  it.  Before  the  tooth  cuts  the  gum  it 
is  completely  enclosed  within  this  capsule.  Under  certain 
conditions  this  capsule  becomes  greatly  increased  in  thickness, 
and  so  thoroughly  encysts  the  tooth  that  it  is  never  erupted 
(Fig.  117).  Such  thickened  capsules  are  mistaken  for  fibrous 
tumours,  especially  if  the  tooth  be  small  and  ill-developed. 
Under  the  microscope  they  present  a  laminated  appearance, 
with  strata  of  calcareous  matter.  To  these  the  term  fibrous 
odontomas  may  be  applied.  They  are  more  common  in  rumin- 
ants than  in  other  mammals,  and  are  especially  frequent  in 
goats.  As  a  rule  they  are  multiple,  four  being  by  no  means 
an  unusual  number.  They  occur  in  marsiipials,  bears,  and 
lions,  as  well  as  in  man. 

There  is  good  reason  for  the  belief  that  rickets  is  responsible 
for  some  of  these  thickened  capsules.  Certainly,  in  some 
of  the  most  typical  examples  which  have  been  observed 
in  human  beings  the  subjects  were  rickety  children ;  the 
bilateral  tumours,  in  some  cases,  being  erroneously  described 
as  myeloid  sarcomas. 

4.  Cementomas.— When  the  capsule  of  a  tooth  becomes 
enlarged,  as  in  the  specimens  just  considered,  and  these  thick 
capsules  ossify,  the  tooth  will  become  embedded  in  a  mass  of 
cementum.  To  this  form  of  odontoma  the  name  cementoma 
may  be  applied.  Tumours  of  this  character  occur  most  fre- 
quently in  horses,  and  sometimes  attain  a  large  size.  Broca 
has  described  and  figured  specimens  from  horses.  Tomes  has 
described  one  which  weighed  ten  ounces,  and  I  have  given  an 
account  of  another  which  weighed  twenty-five  ounces  (Fig. 
118).     When  it  was  divided,  three  teeth  could  be  made  out, 


216 


ODONTOMAS 


embedded  in  cementum.  The  periphery  of  the  tumour  was 
cautiously  decalcified  in  hydrochloric  acid,  and  sections 
were  prepared  for  the  microscope.  The  structure  of  the  de- 
calcified mass  was  very  instructive,  for  the  periphery  of  the 
tumour  exhibited  the  laminated  disposition  seen  in  fibrous 
odontomes. 

The  largest  cementoma  from  a  horse  known  to  me  is 
preserved  in  the  museum  of  the  Koyal  Veterinary  College, 
London;  it  weighs  seventy  ounces,  and,  though  excessively 
dense,   is   nevertheless   very   vascular.      Its   chief  structural 


Fig.  118. — Cementome  from  a  horse.     {JIalfnat.  size.) 
{Museum  of  the  Royal  College  of  Surgeons.) 

peculiarity  is  the  presence,  in  enormous  numbers,  of  large, 
richly  branched  lacunse. 

5.  Compound  follicular  odontomas. — If  the  thickened 
capsule  ossifies  sporadically  instead  of  uniformly  a  curious 
condition  is  brought  about,  for  the  tumour  will  then  contain 
a  number  of  small  fragments  of  cementum^  or  dentine,  or 
even  ill-shaped  teeth  (denticles)  composed  of  three  dental 
elements — cementum,  dentine,  and  enamel.  The  number  of 
teeth  or  denticles  in  such  tumours  varies  greatly,  and  may 
reach  a  total  of  four  hundred. 

Tumours  of  this  character  have  been  described  in  the 
human  subject  by  several  observers.  Amongst  the  most 
noteworthy  are  the  following. 


COMPOUND  FOLLICULAR   ODONTOMAS 


217 


Tellander,  of  Stockholm,  met  with  a  case  in  a  woman 
aged  27  years.  The  right  upper  first  molar,  bicuspids, 
and  canine  of  the  permanent  set  had  not  erupted,  but  the 
spot  where  these  teeth  should  have  been  was  occupied 
by  a  hard,  painless  enlargement,  which  the  patient  had 
noticed  since  the  age  of  12  years.  Subsequently  this  swell- 
ing was  found  to  contain  minute  teeth.  There  were  nine 
single  teeth,  each  one  perfect  in  itself,  having  a  conical 
root,  with  a  conical  crown  tipped  with  enamel ;  also  six 
masses  built  up  of  adherent  single  teeth.  The  denticles 
presented  the  usual  characters  of  supernumerary  teeth  (Fig. 


Fig.  119. — Odontome  (cementoine)  from  the  mandible  of  a  rickety 
youtli  aged  19  years.  A,  denticle ;  b,  portion  of  the  outer  wall 
of  the  jaw. 


120,  a).  About  a  year  afterwards  a  tooth  appeared  in  the 
spot  from  which  this  host  of  teeth  was  removed. 

A  similar  case  has  been  recorded  by  Sir  John  Tomes, 
the  details  of  which  were  communicated  to  him  by  Mr. 
Mathias,  on  medical  service  in  India.  A  Hindoo  aged 
20  had  a  large  tumour  in  his  mouth  containing  a  number 
of  ill-formed  teeth;  fifteen  masses  of  supernumerary  teeth 
and  bone  were  removed  from  it.  The  soft  parts  rapidly 
healed,  the  deformity  disappeared,  and  subsequently  the  only 
peculiarity  noticeable  was  the  absence  of  the  central  and 
lateral  incisors.      The  canines  occupied  their  usual  position. 

A  third  example  of  this  remarkable  condition  has  been 
recorded  by  Windle  and  Humphreys.  The  tumour  was 
found  in  the  mouth  of  a  boy  aged  10  years  ;  neither  the 
deciduous  nor  the  permanent  right  lateral  incisor  or  canine 
had    erupted,      The  space  thus   unoccupied  was    filled  by  a 


218 


ODONTOMAS 


tumour  with  dense,  unyielding  walls.  From  this  tumour 
forty  small  denticles  of  curious  and  irregular  forms  were 
removed.  Ward  Cousens  has  described  one  of  these  remark- 
able tumours  which  grew  in  a  boy  aged  11  years.  He  re- 
moved at  various  times  one  hundred  denticles.  They  are 
preserved  in  the  museum  of  the  Royal  College  of  Surgeons. 


Fig.  120. — A,  Denticles  from  Tellander's  case.     Total  number,  twenty-eight. 
E,  ,,        from  Windle's  case.         Total  numter,  forty, 

c,  „        from  Mathias's  case.        Total  number,  fifteen. 


Hildebrand  and  De  Roaldes  have  observed  similar  cases. 
Logan  reported  an  example  from  the  maxilla  of  a  horse  con- 
taining four  hundred  denticles  ;  and  in  a  Himalayan  goat 
the  writer  found  one  of  these  singular  tumours  in  each 
upper  jaw,  containing  nearly  three  hundred  denticles.  This 
specimen  is  preserved  in  the  museum  of  the  Royal  College 
of  Surgeons. 

6.  Radicular  odontomas. — This  term  is  applied  to  odon- 
tomes  which  arise  after  the  crown  of  the  tooth  has  been 
completed,  and  while  the  roots  are  in  the  process  of  form- 


RADIO  ULAB    ODONTOMAS 


219 


ation.  As  the  crown  of  the  tooth,  when  once  formed,  is 
unalterable,  it  naturally  follows  that,  should  the  root  develop 
an  odontome,  enamel  cannot  enter  into  its  composition ;  the 
tumour  would  consist  of  dentine  and  cementum  in  varying 
proportions,  these  two  tissues  being  the  result  of  the  activity 
of  the  papilla. 

As  a  typical  radicular  odontome  we  may  choose  the  well- 


Fig.  12)  .—Radicular  odontome  from  human  subject,      a  represents  the  natural 
size  of  the  specimen.     (After  Salter.) 

known  specimen  described  by  Salter  (Fig.  121),  in  which  the 
tumour  is  clearly  connected  with  the  roots.  The  outer  layer 
of  the  odontoma  is  composed  of  cementum ;  within  this  is 
a  layer  of  dentine,  deficient  in  the  lower  part  of  the  tumour, 
and  inside  this  is  a  nucleus  of  calcified  pulp. 

A  radicular  odontome  (Fig.  122)  described  by  Sir  John 
Tomes  in  1863,  and  redescribed  by  Mr.  C.  S.  Tomes  m  1872, 
consisted  of  a  mass  invested  by  cementum  ;  inside  this  casing 
IS  a  shell  of  dentine ;  the  tubules  radiate  outwards  and  are 
disposed  with  some  regularity :  this  dentine  was  deficient  at 


220 


ODONTOMAS 


the  distal  end  of  the  tumour ;   its  interior  was  filled   with 
an  ill-defined  osseous  material. 

I    removed   an    odontome  from    a  boy  15  years   of  age. 
An  accurate  diagnosis  was  made  before  the  operation  with 


Fig.  122. — Radicular  odontome,  removed  from  the  upper  jaw  of  a  man 
aged  41  by  Mr.  Hare.     (iV«^.  size.)    {After  Sir  John  Tomes.) 

the  assistance  of  the  X-rays  (Figs.  123  and  124).  The 
tumour  consisted  of  bone  resembling  that  which  forms  the 
alveolar  borders  of  the  jaws,  embedded  in  fibrous  tissue. 
As  shown  in  the  drawings,  the  second  left  mandibular  molar 


Fig.  123. — A,  Odontome  suiToundiug 
the  second  left  mandibular  m.olar  of 
a  boy  aged  15  years. 


B 

B,  The  odontome  in  section,  show- 
ing the  relation  of  the  roots  to  the 
tumour-tissue. 


below  the  neck  of  the  tooth  seems  to  expand  and  become 
gradually  incorporated  with  the  tissue  proper  of  the  odontome. 
It  is  probable  that  some  radicular  odontomes  in  man 
are  due  to  inflammatory  changes  ;  for  example,  the  tumour- 
like swelling  enveloping  the  roots  of  two  molars  (Fig.  125) 


RADICULAR   ODONTOMAS 


221 


supports  this  view.  The  roots  are  embedded  in  an  ossific  ball 
which  microscopically  resembles  a  calcified  and  partially 
ossified  inflammatory  exudate.  The  crown  of  one  of  the  teeth 
carious,   and    the    pulp-chamber   widely   exposed.      This 


IS 


Fig.  124.— Skiagram  showing  the  odontome  illustrated  in  Fig.  123. 


tumour  was  removed  by  Mr.  Murray  from  the  mandible  of  a 
youth  aged  21  years. 

The  curious  odontome  shown  in  Fig.  126  was  extracted 
from  a  Chinese  student  in  Hankow  by  Mr.  Davenport.  There 
was  a  swelHng  around  the  tooth  supposed  to  be  due  to  an 
abscess.     On  a  casual  examination  the  lump  on  the  root  of 


222 


ODONTOMAS 


this  second  lower  molar  appears  as  a  radicular  odontome,  but 
on  section  it  presents  the  complex  structure  of  a  composite 
odontome.  The  clinical  report  contains  the  significant  state- 
ment that  there  were  no  signs  of  the  lower  wisdom  teeth. 


Fig.  125. — Ossific  ball  in  which  the  roots  of  two  molars  are  embedded. 
The  crown  of  one  tooth  is  carious,  a,  The  tumour  entire ;  B,  in 
section.     [JIuseum  of  the  Middlesex  Sospital.) 

Radicular  odontomes  have  been  observed  in  the  marmot, 
the  porcupine,  the  agouti,  and  the  boar  (Figs.  127,  128), 
and  in  elephants. 

It  is  very  probable  that  many,  perhaps  most,  of  these 
thickened  roots  of  tusks   in   boars   and   elephants   and  the 


rig.  126. — Second  right  mandibular  molar  of  a  Chinaman  aged  19  years,  with  a 
tumour  possessing  the  characters  of  a  composite  odontome.  a  and  b,  The 
tooth  of  natural  size  ;  c,  the  tooth  enlarged  and  the  tumour  shown  in  section. 

incisors  of  rodents  are  due  to  inflammatory  changes  in  the 
pulps. 

7.  Composite  odontomas. — This  is  a  convenient  term  to 

apply  to  those  hard   tooth -tumours  which  bear  little  or  no 

resemblance  in  shape  to  teeth,  but  occur  in  the  jaws,  and 


COMPOSITE  ODONTOMAS 


223 


consist  of  a  disordered  conglomeration  of  enamel,  dentine,  and 
cementum.  Such  odontomes  may  be  considered  as  arising 
from  an  abnormal  growth  of  all  the  elements  of  a  tooth- 
germ — enamel-organ,  papilla,  and  follicle. 


Fig.  127. — Left  lower  jaw  of  a  young  marmot  with  a  large  radicular 
odontome  connected  with  the  incisor.     (Nat.  size. ) 

Not  only  is  this  species  of  odontoma  composite  in  that  the 
tumours  comprised  in  it  originate  from  all  the  elements  of  a 
tooth-germ,  but  they  are  composite  in  another  sense  :  many 
of  these  tumours  consist  of  two  or  more  tooth-germs  in- 
discriminately fused.  But  they  differ  from  the  cementomas 
containing  two  or  more  teeth  in  the  fact  that  the  various 
parts   of  the   teeth  composing   the  mass   are   indistinguish- 


Fig.  128. — Radicular  odontome  connected  with  the  mandibular  canine  of  a  boar. 

ably   mixed,  whereas  the  individual   teeth   implicated   in   a 
cementoma  can  be  clearly  defined. 

Forget's  classical  case  belongs  to  this  species.     The  patient 
was  20  years  old,  but  the   disease   had   been   noticed  since 


224 


ODONTOMAS 


tlie  age  of  5  j^ears.  Behind  the  first  bicuspid  no  teeth  were 
seen,  but  the  jaw  as  far  back  as  the  ramus  was  the  seat  of 
a  smooth,  unyielding  tumour  (Fig.  129),  which  consisted 
mainly  of  dentine ;  its  surface  was  in  places  covered  with 
enamel. 

It  was  long  believed  that  composite  odontomas  occurred 
only  in  the  mandible ;  now  that  we  know  more  about  them, 
it  is  clear  not  only  that  they  arise  as  frequently  in  the 
maxillse,  but  that  they  attain  a  far  larger  size  in  the  upper 
than   in    the  lower  jaw.     In    the   mandible   these   tumours 


Fig.  129. — Composite  odontome.     {yat.  size.)     {After  Foryef.) 


may  attain  to  a  large  size.  One  of  the  largest  (Fig.  130) 
was  removed  by  Mr.  Brothers,  of  Cape  Town,  from  a  Kaffir 
boy  aged  14  years.  The  parents  of  the  boy  stated  that  they 
"noticed  a  swelling  when  the  boy  was  6  months  old."  He 
ran  about  the  village  with  part  of  the  tumour  sticking 
out  of  his  mouth :  it  was  extracted  with  a  strong  elevator. 
Many  large  odontomes  removed  from  the  antrum  have 
been  described  as  exostoses.  Thus,  M.  Michon  removed 
from  the  antrum  of  a  Frenchman  aged  19  years,  at  the 
Hopital  de  la  Pitie  (without  an  ansesthetic),  an  odontome 
weighing  1,080  grains.  The  operation,  which  may  be  de- 
scribed as  a  "  surgical  struggle,"  lasted  upwards  of  an  hour 
and  a  quarter.  The  tumour  is  described  as  an  exostosis, 
but  fortunately  Michon's  account  is  accompanied  by    some 


COMPOSITE  ODONTOMAS 


225 


excellent  figures  which  show  clearly  enough  that  the  tumour 
is  of  dental  origin.  The  cut  surface  exhibited  a  laminated 
disposition.  Microscopically  it  was  composed  of  tissue  pre- 
senting many  parallel  tubules  having  the  appearance  of 
exaggerated  dentinal  tubules. 

A  tumour  almost  parallel  with  this  has  been  de- 
scribed by  Dr.  T.  Duka,  by  whom  it  was  removed  from  a 
Mahomedan  woman  aged  26,  at  Monghyr,  Bengal.  The 
woman  had    for    six  years    suffered    from    a   muco-purulent 


Fig.  130. — Composite  odontome  from  the  mandible  of  a  Kaf&r  boy  14  years  of  age. 
(850  grains.)     {^Ihsciou,  Roi/al  Dental  Hospital,  London.) 

discharge  from  the  right  nostril,  and  was  anxious  for  relief. 
The  case  was  regarded  as  one  of  necrosis,  but  after  a"sur- 
gical  struggle"  lasting  nearly  an  hour  (without  chloroform), 
the  tumour  (Fig.  131)  was  withdrawn  from  the  antrum. 
It  had  no  connexion  with  the  surrounding  tissues.  The 
"tumour,  which  was  regarded  as  an  exostosis,  was  sub- 
mitted to  a  committee  of  the  Pathological  Society.  In  its 
report  the  committee  states  that  the  osseous  tissue  differs  in 
character  from  that  ordinarily  seen  in  exostoses.  An  examin- 
ation of  the  tumour,  which  is  preserved  in  St.  George's 
Hospital  museum,  and  inspection  of  the  figures  illustrating 
the  report  mentioned,  show  clearly  enough  that  it  is  a  com- 
posite odontoma.  Dr.  Duka,  in  his  account  of  the  case,  states 
that  Dr.  Allen  Webb  was  of  opinion  that  the  nucleus  was 
formed  by  a  tooth-follicle  escaping  into  the  antrum  of  High- 
more.     This  was  a  guess,  but  one  not  far  short  of  the  truth. 


226 


ODONTOMAS 


The  largest  odontooie  known  to  have  grown  m  the  human 
antrum,  and  which  Hilton  described  as  an  exostosis,  is  pre- 
served in  the  museum  of  Guy's  Hospital  (Fig.  133).  It  has 
an  extraordinary  clinical  history: — 

A  man,  aged  36  years  had  a  large  osseous  tumour 
occupying  the  antrum.  The  pressure  of  this  tumour 
had  caused  the  front  wall  of  the  antrum,  with  the  integu- 
ment and  soft  tissues  covering  it,  to  slough.  The  trouble 
was  first  noticed  thirteen  years  before:  as  the  cheek  en- 
larged the  eyeball  became  displaced  and  finally  burst.  For 
a  long  time  the  surface  of  the  tumour  was  exposed,  the 
suppuration  being  co]3ious,  and  occasionally  pieces  of  bone 


Fig.  131. — Composite  odontome  from  the  iipi^er  jaw.     (Ji^at.  size.) 

irregular  in  shape  came  away ;  at  last,  to  the  man's  astonish- 
ment, the  bony  mass  drojaped  out,  leaving  an  enormous  hole 
in  his  face.  It  weighed  nearly  15  ounces,  and  measured 
27 "5  cm.  (11  inches)  in  its  greatest  circumference.  I  have  had 
an  opportunity  of  investigating  this  tumour  ;  it  is  remarkably 
hard,  presents  on  section  an  ivory-like  surface,  and,  on  close 
scrutiny,  a  number  of  closel}^- arranged  concentric  laminae 
(Fig.  134).  Sections  ground  thin  and  examined  under  the 
microscope  show  large  numbers  of  lacume  and  canaliculi 
arranged  in  a  veiy  regular  manner. 

On  looking  over  a  long  series  of  composite  odontomas  it 
is  curious  to  find  the  great  variety  in  shape,  as  well  as  in  the 


Fig.  132. — Group  of  odoutomes. 

A.  Upper  jaw  (Brock). 

B.  Lower  jaw  (Rushton  Parker). 

C.  Ujjper  jaw  (Jordan  Lloyd). 

D.  Lower  jaw  (Windle). 

E.  Radicular  odontoma  (J.  G.  Turner). 


227 


228  ODONTOMAS 

disposition  of  the  liard  dental  tissues,  which  they  present. 
The  specimen  represented  in  Fig.  135  is  one  of  the  oddest  in 
this  respect,  for  it  in  no  way  recalls  in  its  shape  a  tooth,  yet 
the  whole  of  its  convex  surface  (for  it  is  shell-like  in  form)  is 
occupied  with  well-marked  enamel-covered  projections  resem- 
bling small  supernumerarj^  cusps  on  teeth.  This  tumour  came 
from  an  old  woman,  an  inmate  of  a  workhouse  ;  she  had  been 


Fie 


133. — Large  odontome  -vrliich  was  spontaneously  shed  from  the  antrum ;  weight 
nearly  15  ounces.     {Museum,  Guy''s  Hospital..) 


troubled  with  it  for  very  many  years,  and  one  day  she  "  spat 
it  out." 

Clinical  characters. — The  germ  of  any  permanent  tooth 
may  develop  into  an  odontoma,  and  occasionally  two  or  more 
teeth  may  be  involved  in  the  one  tumour.  Odontomes  occur 
with  equal  frequency  in  the  upper  and  lower  jaws.  The 
follicular  species  is  very  apt  to  be  multiple,  and  four  have 
been  found  concurrently  in  the  jaws  of  the  same  patient. 
The  composite  species  ranks  next  in  frequency.  In  the  upper 
jaw  an  odontome  may  invade  the  antrum  and  attain  the  size 
of  a  child's  fist ;  in  the  mandible  it  rarely  exceeds  a  dove's 


CLINICAL     CHABAGTERS 


229 


Bgg  in  size,  though  in  this   situation  an  oclontome  may  at- 
tain a  good  size  (Fig.  130). 

There  is  a  chnical  point  in  the  natural  history  of  odon- 
tomes  of  some  importance.  A  careful  examination  of  the 
clinical  history  shows  that  in  nearly  all  cases  the  tumours 
have  remained  quiescent,  and  then  there  comes  a  period  in 
which,  like  teeth,  they  seeni  to  erupt  and  make  their  way 
above  the  gum,  and  very  often  cause  profound  constitutional 
disturbance,  mainly  of  a  septic  character.  In  some  reported 
cases  it  is  stated  that  the  patients  have  been  so  ill  as  to  be 


Fig.  134. — Section  of  tumour  shown  in  Fig.  133,  exhibiting  concentric  lamination. 


near  death.  This  phenomenon  usually  happens  between  the 
twentieth  and  the  twenty-fifth  years.  In  a  fair  number  of 
cases  relief  has  come  to  the  patient  and  the  illness  has 
ended  by  the  tumour  loosening  spontaneously.  In  several 
instances  it  is  said  that  the  patient  "spat  it  out."  This 
happened  with  the  specimens,  Figs.  132,  d,  and  135.  One 
of  the  largest  odontomes  known,  after  producing  hideous 
deformity  of  the  face  and  sloughing  of  the  cheek,  fell  out 
of  its  own  accord. 

The  diagnosis  of  these  tumours  has  been  a  matter  of  Q-reat 
difficulty  in  the  past.  In  many  the  swelhng  has  been 
regarded  as  a  myeloma,  or  a  sarcoma,  but  in  the  majority 
of  cases,  especially  where  there  has  been  free  suppuration 
around  the  tumour,  it  has  been  regarded  as  a  piece  of  dead 
bone.  The  X-rays  have  been  serviceable  in  enabling  a  correct 
diagnosis  to  b.e  made  {see  Fig.  124). 


230 


ODONTOMAS 


Treatment, — A  study  of  the  literature  relating  to  the 
treatment  of  odontomas  is  very  instructive,  because  it  re- 
veals that  operations  unnecessarily  severe  have  been  under- 
taken, in  ignorance  of  the  nature  of  the  disease,  by  surgeons 
of  high  reputation  and  Avide  experience.  In  several  instances 
it  is  known  that  a  great  portion  of  the  mandible  has  been 
excised  under  the  impression  that  the  tumour  was  malig- 
nant in  nature.  In  some  verv  large  odontomes  of  the 
upper  jaw  the  tumour  has  been  removed  without  an  anaes- 
thetic, the  procedure  being  described,  in  the  words  of  the 
operator,  as  "  a  surgical  struggle  "  (Duka,  Michon).     In  some 


A  B 

Fig.  135. — Composite  odontomes  from  the  mandible:  A,  the  upper, 
B,  the  lower  view.     {Museum  of  the  Middlesex  Hospital.) 

of  the  cases  dentists  succeeded  in  removing  the  tumour 
with  forceps,  thinking  they  were  dealing  with  unerupted 
(buried)  teeth  (Davenport),  In  other  instances  the  nature  of 
the  tumour  has  been  suspected,  but  in  the  course  of  its 
excision  the  mandible  has  been  broken  and  has  remained 
permanently  ununited. 

In  the  case  of  a  tumour  of  the  jaw  the  nature  of  which 
is  doubtful,  particularly  in  a  young  adult,  it  is  incumbent 
on  the  surgeon  to  satisfy  himself,  before  proceeding  to  excise 
a  portion  of  the  mandible  or  maxilla,  that  the  growth  is 
not  an  odontome,  for  this  kind  of  tumour  only  requires 
enucleation.  In  the  case  of  a  follicular  odontome  it  is  very 
essential  to  remove  the  sac  completely. 

Dental  cysts. — It  occasionally  happens  in  extracting  per- 
manent teeth  that  a  small  fibrous  bag  is  found  at  the  apex  of 


DENTAL    GYSTS 


231 


the  root,  usually  no  larger  than  an  apple  pip,  though  some- 
times it  may  be  as  big  as  a  bantam's  egg,  filled  with  fluid, 
and  often  containing  crystals  of  cholesterin.  These  sacs, 
or  dental  cysts,  occur  in  connexion  with  the  dead  roots  of 
mandibular  and  maxillary  teeth,  especially  molars  and  pre- 
molars. They  sometimes  attain  a  considerable  size  in  the 
upper  jaw  when  they  invade  the  antrum,  and  some  of 
these  cysts  are  sufficiently  large  to  simulate  an  abscess  of 
the  cavity.  Dental  cysts  are  often  bilateral, 
and  occasionally  multiple. 

The  constant  association  of  these  cysts 
with  the  dead  roots  of  permanent  teeth  has 
led  many  observers  to  regard  them  as  pus- 
sacs  with  thick,  fibrous  walls.  Mr.  J.  G. 
Turner  has  carefully  investigated  their  struc- 
ture, and  demonstrated  the  existence  of 
an  epithelial  lining  in  many  dental  cysts. 
He  believes  that  they  arise  in  the  "  rests  " 
detected  by  Malassez  and  known  as  para- 
dental epithelial  remnants.  They  are  de- 
rived from  a  prolongation  of  the  enamel- 
organ  which  precedes  and  determines  the 
formation  and  shape  of  the  dentine  and  the 
root  of  the  tooth. 

I    have    had    several    dental    cysts    ex- 
amined microscopically,  and  can   confirm  Turner's   observa- 
tion that  they  possess  an  epithelial  lining.     The  epithelium 
is  usually  stratified,  but  columnar  cells  occur,  especially  in 
cysts  associated  Avith  the  first  permanent  molar. 

The  restriction  of  these  cysts  to  the  roots  of  the 
permanent  teeth  is  explained  by  the  fact  that  the  roots 
of  temporary  teeth  as  Avell  as  their  alveoli  are  absorbed. 

The  majority  of  dental  cysts  are  met  with  accidentally 
in  extracting  dead  permanent  teeth  or  their  roots.  Large 
specimens,  however,  resemble  in  their  clinical  signs  tumours 
of  the  jaws  or  antrum  (Fig.  137).  Even  cysts  of  the  size 
of  a  dove's  egg  in  relation  with  the  lower  molars  and  pre- 
molars will  so  expand  the  outer  plate  of  the  mandible  as 
to  yield  parchment-crackling  on  being  firmly  pressed  with 
the  finger.     When  a  painless  smooth  tumour  of  the  jaw  is 


Fig.  136.— Dental 
cysts  at  the  roots  of 
a  dead  lower  molar. 


232 


ODONTOMAS 


associated  with  a  carious  tooth,  especially  of  long  standing, 
a  dental  cyst  should  be  borne  in  mind.  The  association  ot" 
these  cysts  with  carious  and  dead  teeth  is  sufficient  to  pre- 
vent them  from  beinsf  mistaken  for  follicular  odontomes. 


Fig.  137.— Large  cyst  connected  with  the  mandible ;    it  is  probably  an  unusually 
large  dental  cyst.     [Muscmn,  St.  George''s  Hosjntal.) 

Treatment. — The  roots  must  be  extracted,  and  the  cyst- 
wall  thoroughly  enucleated,  and  the  cavity  stuffed  with  ste- 
rilized gauze  and  allowed  to  granulate.  If  any  part  of  the 
cyst-wall  be  allowed  to  remain  it  will  lead  to  a  persistent 
and  usually  troublesome  sinus. 


REFERENCES  233 

Bland-Sutton,  J.,   "A  Yeiy  Large  Oclontome  from  a  Horse." — Trans.  Odont. 
Sac.  Gt.  ISrlt.,  1891,  xxiii.  215. 

Bland-Sutton,  J.,   "An  Anomalous  Tumour  from  the  Antrum." — Ihid.,  190'i, 
xxxiv.  9G. 

Bland-Sutton,  J.,  "  On  a  Radicular  Odontoma  from  the  Mandible." — Ibid.,  1906, 
xxxviii.  19. 

Broca,  Paul,  "  Odontomes." — "  Traite  des  Tumeurs,"  1869,  ii.  350. 

Colyer,   J.    F.,   "  On   some  Odontomes  and  Anomalous-shaped   Teeth   in   the 
Museum  of  the  Society  ."—Trans.  Odont.  Soc.  Gt.  Brit.,  1906,  xxxviii.  245. 

Cousens,  W.  J.,  "A  Case  of  Compound  Follicular  Odontoma." — Lancet,  1908, 
i.  1352. 

Duka,  T.,   "A  Bony  Tumour  of  the  Nasal  Fossa." — Tra-ns.  Path.  Soc,  1866, 
xvii.  256. 

Eve,  F.  S.,  "On  Cystic  Tumours  of  the  Jaws.''— Brit.  Med.  Journ.,  1883,  iii.  1. 

Heath,  C,  "  Injuries  and  Diseases  of  the  Jaw." 

Hildebrand,  Zeitschr.f.  Chir.,  1891,  xxxi.  282. 

Hilton,  J.,  "A  Large  Bony  Tumour  of  the  Face." — Guy's  Hasp.  Eepts.,  1836, 
i.  493. 

Hopewell-Smith,  A.,  "Two  Odontoceles  and   some  other  Cysts." — Proc.  lioy. 
Soc.  of  Med.,  Odont.  Sec,  1910,  iii.  121. 

Mathias,  "A  Group  of  Supernunaerary  Teeth.." --Trans.  Odont.  Soc.  Gt.  Brit., 
1863,  iii.  365. 

Michon,  "  Exostose  eburnee  du    Sinus   maxillaire." — Mem.  de  la  Soc.   Chir., 
Paris,  1850,  i.  608. 

de  Roaldes,  "  A  Compound   Follicular  Odontome." — New  Yorh  Med.  Journ., 
1894,  lix.  612. 

Smale,  Morton,  Trans.  Odont.  Soc.  Gt.  Brit.,  xxxv. 

Tomes,  Chas.  S.,  "Description  of  an  Odontome." — IMd.,  1872,  iv.  81. 

Tomes,  Chas.  B.~Ibid.,  1872,  iv.  103. 

Tomes,  Sir  J.,  "  A  Remarkable  Case  of  Exostosis." — Ibid.,  1863,  iv.  335. 

Windle,  B.,  and  Humphreys,  J.,  "  A  Rare  Tumour  connected  with  the  Teeth." 
— Journ.  of  Anat.  and  Phys.,  1887,  xxi.  667. 


GROUP  III.    EPITHELIAL  TUMOURS 

CHAPTER    XXII 
PAPILLOMAS  (WARTS) 

Ix  the  group  of  tumours  now  to  be  considered,  epithelium 
is  not  only  present,  but  is  the  essential  and  distinguishing- 
feature.  Epithelium  is  so  disposed  in  the  bodies  of  complex 
animals  as  to  serve  many  functions  :  in  some  situations  it 
acts  as  a  protective — e.g.  the  epidermis,  where  it  becomes 
modified  into  hair,  nail,  horn,  or  into  the  hardest  of  all 
animal  tissues — enamel;  in  others,  epithelial  cells  dip  into 
the  underlying  connecting  tissue  to  form  secreting  glands; 
some  of  them  are  simple — e.g.  the  tubular  glands  of  the 
intestine ;  others  are  very  complex — e.g.  the  liver,  mamma, 
and  kidney.  Whether  a  gland  is  simple  or  complex,  the 
principle  of  its  construction  is  identical— namely,  narrow 
channels  lined  with  epithelium,  resting  upon  a  connective- 
tissue  base,  in  which  blood-vessels,  lymphatics,  and  nerves 
ramify. 

Each  e]3ithelial  recess  of  a  gland  is  known  as  the  acinus, 
and  each  acinus  is  in  communication  with  a  free  surface, 
either  directly  by  its  own  duct,  as  in  the  case  of  seba- 
ceous and  mucous  glands,  or  indirectly  by  means  of  a 
number  of  main  ducts,  as  in  the  case  of  the  mamma; 
or  by  a  common  duct,  as  in  the  pancreas.  To  this  rule 
there  are  exceptions :  the  thyroid  gland,  the  pituitary  body, 
and  the  ovary. 

The  various  members  of  the  epithelial  group  of  tumours 
fall  readily  into  three  genera:  1,  papillomas  (warts);  2,  ade- 
nomas ;  3,  carcinomas  (cancers).  In  this  and  the  next 
chapter  papillomas  and  horns  will  be  considered,  the  other 
two  genera  being  dealt  with  in  later  chapters. 

2U 


PAPILLOMAS 


235 


PAPILLOMAS 

A  papilloma  or  wart  consists  of  an  axis  of  fibrous 
tissue,  containing  blood-vessels,  surmounted  by  epithelium, 
projecting  from  an  epithelial  surface ;  it  may  be  simple,  and 
present  a  uniform  surface,  or  be  so  covered  with  secondary 
processes  as  to  look  like  a  mulberry.  When  the  processes 
are  long  the  papilloma  has  a  villous  appearance. 


Fig.  138. — Horn  which  grew  from  a  wart  on  the  cheek  of  a  very  old  Welsh 
woman  ;  it  measured  21  cm.  along  its  greater  curve. 

Warts  are  most  common  on  the  skin,  but  they  also 
arise  from  mucous  surfaces  covered  with  squamous  epithe- 
lium. They  occur  singly  or  in  multiples ;  occasionally  they  are 
thickly  crowded  on  a  restricted  area  of  the  skin,  and  form 
a  wart-field.  Warts  are  rarely  painful  unless  irritated,  then 
they  are  apt  to  ulcerate  and  bleed.  Crops  of  warts  are  often 
seen  on  the  hands  of  children.  They  are  common  in  the 
region  of  the  anus,  vagina,  and  glans  penis  when  these 
parts  are  irritated  by  foul  discharges,  especially  those  of 
gonorrhceal  origin.  A  curious  feature  of  multiple  warts  is 
that  they  sometimes  appear  on  the  hands    or   scalp  almost 


236  EPITHELIAL   TUMOURS 

suddenly,  and  after  persisting  many  weeks,  or  perhaps 
months,  disappear  as  if  by  magic.  When  warts  are  thickly 
crowded  upon  a  limited  area  of  skin — as,  for  example,  the 
glans  penis— they  may  be  mistaken  for  a  more  serious  dis- 
ease, such  as  wart}^  carcinoma.  When  they  appear  in  great 
number,  they  are  due  to  local  infection  by  micro-organisms. 

Skin-warts  are  overgrown  papilla3,  and  on  section  the 
epithelium  will  be  found  to  pass  from  one  papilla  to  another 
in  an  unbroken  line  without  invading  the  fibrous  frame- 
work. 

A  solitary  wart  may  occur  on  any  skin-covered  surface 
and  persist.  A  wart  of  this  character  sometimes  attains  the 
size  of  a  walnut,  and  in  some  cases  is  mottled  with  black 
pigment.  Such  warts,  late  in  life,  may  become  the  starting- 
points  of  melanomas.  Occasionally  one  or  two  sparse  hairs 
may  be  detected  on  a  wart ;  and  some  fun  is  made  out  of 
this  fact  by  Cressida  when  her  uncle  Pandarus  says  con- 
cerning the  glabrous  chin  of  Troilus: 

"  And  she  takes  upon  her  to  spy  a  white  hair  on  his  chin." 

Cressida  replies : 

"  Alas,  poor  chin !     Many  a  wart  is  richer." 

Troilus  and  Cressida,  i.  2. 

Solitary  warts  sometimes  grow  rapidly,  and  become  so 
large  that  they  are  apt  to  be  mistaken  for  malignant 
tumours.  They  are  red,  like  the  comb  of  a  cock,  and 
smeared  with  purulent  material,  and  often  very  fetid. 
Billroth  drew  attention  to  large,  rapidly  growing  tumours 
of  this  kind  arising  in  soft  warts  of  the  face,  and  termed 
them  plexiform  sarcomata  (see  also  McCarthy  and  Bland- 
Sutton). 

Warts  growing  from  the  skin  are  covered  with  squamous 
epithelium,  and  the  surface  cells  are  liable  to  be  transformed 
into  horny  material  and  form  what  are  called  cutaneous 
horns.  Some  of  these  wart-horns  have  attained  almost 
fabulous  dimensions  (Fig.  138).  Warts  are  by  no  means 
uncommon  in  domesticated  animals.  They  are  frequent  on 
the  penis  of  horses  and  bulls,   the  lips   of  lambs,   and    the 


PAPILLOMAS 


237 


pads  on  the  feet  of  dogs  and  cats  and  cat-like  mammals 
(Felida)). 

Warts  similar  in  structure  to  those  of  the  skin  occur  on 
mucous  membranes  with  a  covering  of  squamous  epithelium, 
such  as  the  lips,  buccal  aspect  of  the  cheeks,  vestibule  of 
the  nose,  and  the  larynx.  The  oesophagus  of  the  ox  is  occa- 
sionally the  seat  of  a  multitude  of  dendritic  warts. 

Laryngeal  warts. — In  the  larynx,  warts  most  commonly 
spring  from  the  mucous  membrane  covering  the  true  cords  ; 


Fig.  139. 


-Larynx  of  a  child  opened  jjosteriorly ;  it  is  full  of  warts, 
from  suffocation. 


The  child  died 


frequently  they  grow  immediately  beneath  the  cords,  and  a 
not  uncommon  situation  is  immediately  below  the  point  of 
attachment  of  the  vocal  cords  to  the  thyroid  cartilage.  Ex- 
ceptionally a  large  mulberry-like  wart  has  been  detected 
growing  from  the  floor  of  the  sinus  pyriformis.  In  number 
laryngeal  warts  vary  greatly.  Often  but  one  is  present;  in  other 
cases  ten  or  more  will  be  found.  In  size  there  is  great  differ- 
ence :  some  Avarts  are  not  larger  than  the  head  of  a  pin ;  they 
rarely  exceed  the  dimensions  of  a  small  cherry,  and  as  a  rule 
they  are  no  bigger  than  split  peas.  The  warts  may  be  sessile 
or  pedunculated;  in  the  latter  case  they  sometimes  possess 
great  mobility,  and  get  nipped  between  the  vocal  cords  and 


238  EPITHELIAL   TUMOURS 

o-ive  rise  to  urgent  dyspnoea,  which  occasionally  ends  in 
suffocation  (Fig.  139).  In  colour  they  are  of  a  delicate  pink, 
sometimes  of  a  whitish  tint  resembling  that  of  the  healthy 
cords.  Haemorrhage  into  their  substance  causes  them  to 
assume  a  deep -red  tint. 

Laryngeal  warts  occur  in  children  and  adults.  A  curious 
feature  connected  with  them  in  children  is  their  disappear- 
ance after  tracheotomy.  This  is  similar  to  the  sudden 
manner  in  which  warts  on  the  skinsome  times  vanish. 

Intracystic  warts. — This  variety  of  papilloma  frequently 
grows  in  mauniiary  cysts,  especially  those  which  arise  in  the 
sinuses  of  the  galactophorous  ducts.  Warts  of  this  kind  are 
associated  with  the  disease  known  as  duct-cancer  of  the 
breast  (see  Chap.  xxix.). 

The  remarkably  luxuriant  papillomas  which  arise  in  the 
cysts  of  the  hilura  of  the  ovary  are  described  in  the  section 
dealinsr  with  Tumours  of  the  Genital  Glands. 

Papillomas  grow  in  the  small  cysts  formed  by  dilatation 
of  sweat-glands.  They  have  been  observed  in  the  axilla 
(Robinson)  and  on  the  cheek  (Rolleston). 

Adams  has  made  a  careful  histologic  examination  of 
the  cysts  which  arise  in  the  condition  known  as  hydro- 
cystoma.  These  cysts,  which  do  not  exceed  in  size  barley- 
corns, are  limited  to  the  face,  and  arise  from  an  abnormal 
dilatation  in  the  coil  of  the  sweat-glands.  The  epithelial 
lining  of  such  cysts  is  always  very  rich,  and  they  sometimes 
contain  intracystic  growths. 

Villous  papillomas. — These  grow  from  the  mucous 
membrane  of  the  bladder,  the  renal  pelvis,  and  the  choroid 
plexuses  of  the  ventricles  of  the  brain.  In  the  bladder  the 
general  appearance  of  the  long,  branching,  feathery  tufts 
recalls  in  a  striking  manner  the  delicate  chorionic  viUi,  and 
when  viewed  with  the  cystoscope  in  the  living  bladder  they 
are  often  exquisite  objects.  They  consist  of  a  connective-tissue 
core  traversed  by  delicate  blood-vessels,  the  whole  being 
surmounted  by  epithelium. 

These  villous  growths  sometimes  have  broad  bases,  but  in 
other  cases  the  points  of  attachment  are  so  narrow  that  the 
tumours  may  be  described  as  pedunculated.  Usually  villous 
tumours  of  the  bladder  occur  singly,  but  two,  three,  or  more 


PAPILLOMAS  239 

may  be  fonnd  in  the  same  bladder.  Occasionally  there  is  one 
large  villous  tuft  with  several  smaller  masses  of  the  size  of 
peas.  In  some  instances  they  occur  at  or  near  the  orifice  of 
the  ureter,  and,  though  small,  the  tumour  will  give  rise  to 
serious  changes  in  the  corresponding  kidney  by  obstructing 
the  flow  of  urine  from  the  ureter.  When  the  papilloma  is 
situated  near  the  neck  of  the  bladder  the  long  villous  tufts 
will  sometimes  be  carried  by  an  overflowing  current  of  urine 


Fig.  140. — Villous  papilloma  of  the  bladder. 

into  the  urethral  orifice,  and  cause  imjiediment  to  its  free 
escape  (Fig.  140).  The  delicate  character  of  the  villi  and 
their  vascularity  are  sources  of  danger,  because  the  processes 
themselves  are  sometimes  torn,  and  the  hsemorrhasre  is  occa- 
sionally  so  severe  as  to  place  life  in  great  peril. 

Villous  growths  in  every  way  identical  with  those  found  in 
the  bladder  are  sometimes  found  growing  from  the  pelvis  of 
the  kidney  (Fig.  141).  In  one  very  striking  case  of  this  sort 
recorded  by  Murchison  the  pelves  of  the  kidneys  of  a 
man  65  years  of  age  were  found  thus  occupied,  and  a 
singular  feature  of  the  case  was  the  presence  of  two  villous 


240 


EFITHELIAL   TUMOURS 


tumours  in  tlie  bladder,  one  at  the  orifice  of  each  ureter.  It 
is  not  improbable,  from  what  we  know  of  the  habits  of  warts 
generally,  that  in  this  exceptional  instance  the  vesical  warts 
were  due  to  transplantations  of  epithelium  from  the  pelvis  of 
the  kidney  to  the  mucous  membrane  of  the  bladder.  The 
passage   of  detached  villous   tufts   down   the  ureter   caused 


Fig.  lil. — Kidney  with  a  villous  papilloma  growing  in  its  pelvis. 

colic  like  a  renal  calculus   in   a  man  in  his  eightieth  year 
(Lendon). 

Villous  papilloma  of  the  renal  pelvis  is  a  somewhat  rare 
affection,  and  the  subjects  are  generally  past  middle  life ;  the 
condition  is  often  bilateral,  and  simulates  cancer  of  the 
kidnej'-.  The  reported  cases  have  been  collected  by  Nash  and 
Savory.  If  care  be  taken  to  exclude  cases  of  carcinoma  of  the 
kidney  with  villous  tufts,  true  villous  disease  of  the  kidney 
will  be  found  a  rare  condition. 


FAFILL0MA8  241 

There  is  an  interesting  variety  of  villous  papilloma  which 
arises  from  the  choroid  plexuses  of  the  cerebral  ventricles. 
These  plexuses  are  fringed  with  tufts  of  epithelial-covered  villi 
which  occasionally  grow  luxuriantly  and  attain  a  size  sufficient 
to  give  rise  to  unpleasant  effects,  particularly  when  the 
choroid  plexus  of  the  fourth  ventricle  behaves  in  this  manner. 
Douty  described  a  case  of  "  villous  tumour  of  the  fourth 
ventricle"  in  which  the  tumour  was  as  large  as  a  bantam's 
e^^ ;  it  obstructed  the  interventricular  communications  and 
led  to  distensions  of  the  lateral  and  third  ventricles ;  the 
aqueduct  of  Sylvius  was  dilated  to  the  size  of  a  quill.  The 
patient  was  a  boy  17  years  old,  and  the  clinical  features 
were  such  as  to  permit  of  accurate  localization  of  the  lesion 
during  life.  I  had  an  opportunity  of  examining  this  speci- 
men. Similar  cases  have  been  reported  by  Clifford  Allbutt, 
Ashby,  and  Briichanow. 


Allbutt,  Sir  T.  Clifford,  "  Two  Cases  of  Tumour  of  the  Pons  Varolii." — Trans. 
Path.  Soc,  1868,  xix.  20. 

Ashby,  H.,  "  Angio-Sarcoma  of  Left  Choroid  Plexus." — Trans.  Path.  Soc,  1886, 
xxxvii.  56. 

Billroth,  Th.,  "Lectures  on  Surgical  Pathology  and  Therapeutics." — Translated 
from  the  8th  edit.  (i\^ew  Syd.  Soc),  1878,  ii.  414-415. 

Bland-Sutton,  J.,  "An  Unusual  Form  of  Wart  (Plexiform  Sarcoma — Billroth)." 
—  Trans.  Path.  Soc,  1892,  xliii.  161. 

Briichanow,  N.,  "  Ueber  einen  Fall  von  Papillom  des  Plexus  Choroideus 
ventriculi  lateralis  sin.  bei  einem  2^  j.  Knaben.'" — Prag.  med.  Woch.,  1898, 
xxiii.  585. 

Douty,  J.  H.,  "  Notes  and  Remarks  upon  a  Case  of  Villous  Tumours  in  the 
Fourth  Ventricle." — Brain,  1886,  viii.  409. 

McCarthy,  Jeremiah,  "Tumour  of  Face,  Plexiform  Sarcoma." — Trans.  Path. 
Soc,  1880,  xxxi.  256. 

Murchison,  C,  "Case  of  Villous  Disease  of  the  Bladder  and  Kidneys." — Trans. 
Path.  Soc,  1870,  xxi.  241. 


CHAPTER    XXIII 
HORNS 

Cutaneous  horns  in  the  human  subject  are  of  four  varieties  : 
1,  Sebaceous  horn;  2,  Wart-horn;  3,  Cicatrix-horn ;  4,  Nail- 
horn. 

Sebaceous  and  wart-horns  are  structurally  identical.  It 
is  impossible  to  decide  from  an  examination  of  a  large  horn 
whether  it  grew  from  a  sebaceous  cyst  or  from  a  wart. 
Cutaneous  horns  sometimes  attain  great  proportions,  espe- 
cially in  the  aged  (Fig.  138).  Sebaceous  horns  are  more 
frequent  on  the  scalp  than  elsewhere,  whilst  wart-horns  are 
most  frequently  found  on  the  penis,  and  are  not  rare  on  the 
pinna.  It  is  important  to  bear  in  mind  that  carcinoma  is 
apt  to  originate  in  the  skin  around  the  bases  of  wart-horns, 
especially  in  elderly  patients. 

Cutaneous  horns  are  extremely  tough,  and  present  a  longi- 
tudinal fibrillation;  when  soaked  in  a  weak  solution  of 
liquor  potassse  they  quickly  soften,  and  the  horny  material 
comes  away  in  flakes. 

The  only  means  of  deciding  between  a  wart-horn  and  a 
sebaceous  horn  is  by  dividing  them  longitudinally,  and  ascer- 
taining the  existence  or  otherwise  of  a  cyst  at  the  base  of 
the  horns.  In  the  case  of  the  mouse  sketched  in  Fig.  142, 
some  pathologists  who  examined  it  were  of  opinion  that  it 
was  a  wart-horn,  but  on  dissection  a  large  sebaceous  cyst 
was  found  to  occupy  its  base.  Horns  of  this  character  are 
not  rare  in  mice,  and  have  been  seen  on  a  mouse  which 
lived  in  a  church,  and  on  one  which  was  caught  in  West- 
minster Abbey  (W.  G.  Spencer). 

The  most  elaborate  collection  of  cases  illustrating  cuta- 
neous horns  is  contained  in  a  small  work  published  by  Dr. 
Hermann  Lebert.  He  gives  accounts  of  one  hundred  and 
nine  cases,  with  references,  the  earliest  dating  from  the  year 

242 


HOBNS 


243 


1300.  The  horns  were  found  on  the  scalp,  temple,  forehead, 
eyelid,  nose,  lip,  cheek,  shoulder,  arm,  elbow,  thigh,  leg,  knee, 
toe,  axilla,  thorax,  buttock,  loin,  penis,  and  scrotum.  In  length 
they  varied  from  1  to  20  cm.  Lebert,  however,  makes  no 
attempt  to  discriminate  between  the  varieties  of  horns. 

The  most  curious  situation  in  which  cutaneous  horns 
occur  is  in  ovarian  dermoids.  The  conversion  of  epithe- 
lium into   horn   in  cases   of  sebaceous    cysts   and  warts   is 


Fig.  142. — Sebaceous  horn  in  a  mouse. 

something  more  than  desiccation  from  exposure  ;  it  is  doubt- 
less akin  to  the  change  by  which  nail  and  horn  are  formed 
under  normal  conditions. 

A  good  physiological  type  of  a  cutaneous  horn  is  pre- 
sented by  the  nasal  horn  of  the  rhinoceros.  This  formidable 
cutaneous  appendage  is  composed  of  agglutinated  hairs. 
Professor  Flower  exhibited  at  the  Zoological  Society,  London, 
a  portion  of  the  skin  from  the  head  of  a  rhinoceros  (shot 
by  Sir  John  Willoughby  in  Central  Africa)  furnished  with 
three  horns.  The  accessary-  horn  was  12  cm.  high  and  42  cm. 
in  circumference  (Fig.   143). 

A  physiological  type  of  sebaceous  horns  is  furnished  by 
the  curious  patch  of  spines  on  the  forearm  of  Hapalemur 
(Hcqxdemur  griseus).  It  is  present  only  in  the  adult  male. 
The  spines  are  identical  in  structure  with  sebaceous  horns, 


2U 


EPITHELIAL   TUMOUES 


and  are  formed  of  hardened  secretion  furnislied  by  a  mul- 
titude of  glands  in  the  skin  immediately  underlying  the 
patch  of  spines.  The  male  ring-tailed  lemur  (Lemur  catta) 
has  a  curious  hom-like  spur  upon  its  forearm  near  the  wrist ; 
beneath  this  horny  patch  I  found  a  collection  of  glands. 

Cutaneous  horns  are  sometimes  found  on  cows,  sheep, 
and  goats.  They  may  attain  a  large  size.  The  museum  of 
the  Royal  College  of  Surgeons  contains  a  very  large  horn 
that  grew  from  the  flank  of  a  ram.  It  is  nearly  a  metre 
in  length,  and  in  its   dried  condition  is  28  cm.  in  circum- 


rig.  143.^Head  of  an  African  rhinoceros  with  a  large  wart  posterior  to  and  in  a 
line  with  its  nasal  hoi^ns. 


ference  at  the  base.  This  specimen  is  described,  with  others, 
by  Sir  Everard  Home  in  an  interesting  paper  (Phil.  Trans., 
1791).  Rabelais  tells  us  that  the  mare  on  which  Gargantua 
rode  to  Paris  had  a  little  horn  on  her  buttock. 

Birds  are  liable  to  cutaneous  horns:  they  grow  very 
rapidly,  and  sometimes  attain  great  lengths.  They  follow 
the  rule  with  regard  to  the  epidermic  structures  in  this  class 
generally,  and  are  cast  oft"  when  the  birds  moult   (Fig.  144). 

A  good  physiological  type  of  wart-horn  among  birds  is 
furnished  by  the  American  white  pelican,  P.  tra.chyrhynchus. 
The  beak  of  this  bird  is  furnished  with  a  horn  structurally 
resembling  the  wart-horns  occasionally  seen  on  other  birds. 
The  horn  is  shed  in  the  autumn  Avhen   the  pelican  moults. 


EOBNi^ 


245 


and  is  rapidly  reproduced  with  the  feathers.  Mr.  Spencer 
F.  Baird  states  that  Mr.  Ridgway  visited  the  breeding-ground 
of  these  birds  on  an  island  in  Pyramid  Lake,  Nevada,  and 
found  the  pelicans  nesting  by  thousands.  Towards  the  end 
of  the  season  the  oround  became  so  strewn  with  these  shed 
horns  that  they  could  be  gathered  by  the  bushel. 


Fig.  144, 


-Head  and  leg  of  a  thrush  with  cutaneous  horns, 
each  time  the  bird  moulted. 


The  horns  were  cast 


Cicatrix  -  horns. — These  are  rare,  and  grow  generally 
from  the  scar  left  by  a  burn.  Such  scars,  when  extensive, 
are  liable  to  ulcerate  and  then  slowly  heal  again,  but  as  they 
heal  they  become  covered  with  a  mass  of  scales,  which  some- 
times form  a  horny  outgrowth  composed  of  hard  desiccated 
tissue,  often  laminated  like  a  pie-crust. 

Cruveilhier  described  a  very  remarkable  example  of  this 
kind  of  horn  growing  from  a  hand,  probably  deformed  in 
consequence  of  a  burn  ;  the  horny  processes  vary  from  2  to 


246 


EPITHELIAL   TUMOURS 


20  cm.  in  length.  Edmimfls  has  described  and  figured  a 
similar  specimen.  Cruveilhier  states  that  horns  of  this  kind 
came  under  his  notice  on  the  thighs  of  an  old  woman  at  the 
Salpetriere ;  the}^  grew  from  the  scars  of  old  burns  caused  by 
chaufferettes.  When  the  horns  became  detached  they  left 
painful  ulcers.  Later  observations  show  that  as  these  ulcers 
heal,  new  horns  form. 

Nail-horns  do  not  call  for  much  consideration.     They  are 


Fig.  145. — American  white  pelican,  P.  trachyrhynchus.     {From  a  specimen  in  the 
Zoological  Gardens,  London.) 

extremely  common  on  the  toes  of  bedridden  patients,  espe- 
cially old  women  and  those  who  are  dirty.  Although  nail- 
horns  may  grow  on  any  of  the  toes,  they  are  most  frequently 
met  with  on  the  big  toe.  The  horns  may  attain  a  length  of 
7  cm.,  and  become  twisted  so  as  to  resemble  rams'  horns. 

Treatment. — Cutaneous  horns  are  easily  detached  by  a 
sudden  jerk  with  the  thumb  and  forefinger;  if  they  are  too 
firmly  fixed  to  be  removed  in  this  way,  then  they  may  be 
excised.  An  exceptional  case  will  demand  amputation,  and 
in  a  few  instances  surgeons  have  thought  it  necessary  to 
remove  the  extremity  of  the  penis  when  the  skin  surrounding 
the   base   of  the   horn   has   been  ulcerated.     When   cancer 


HORNS  247 

attacks  the  skin  at  the  base  of  a  horn,  it  should,  with  the 
surrounding  skin,  be  early  and  freely  excised,  and  the  lymph- 
glands  connected  with  it  should  be  carefully  dissected  out, 

Baird,  Spencer  F.,  Ibis,  18G9,  p.  350. 

Bland-Sutton,  J.,  "Arm  Glands  of  Lemurs." — Proc.  ZooL  Soc,  1887,  p.  3G9. 
Cruveilhier,  "  Anatomie  Pathologique  du  Corps  Humain  ;  ou,  descriptions  avec 
figures  de  ses  Diverges  Alterations." — Morhides,  1835,  pi.  vi,,  livraison  vii. 

Edmunds,   Walter,   "  Horny  Papilloma  of  Hand." — Trans.  .Path.  Soc,    1887, 
xxxviii.  352. 

Flower,  Sir  WilJiam,  Proc.  ZooJ.  Soc,  1889,  p.  448. 

Lebert,  Hermann,  "  Ueber  Keratose,"  Breslau,  1864. 

Spencer,  W.  G.,  "Epithelioid  Horn  on  a  Mouse." — Trans.  Path.  Soc,  xli.  402. 

Willougliby,  Sir  J.  C,  "  East  Africa  and  its  Big  Game,"  1889,  p.  155. 


CHAPTER    XXIV 
ADENOMA 

An  adenoma  is  a  tumour  constructed  upon  the  type  of,  and 
growing  in  connexion  with,  a  secreting  gland. 

Adenomas  occur  as  encapsuled  tumours  in  such  organs 
as  the  mamma  and  liver,  and  in  glands  like  the  parotid  and 
thyroid ;  in  the  mucous  membrane  of  the  rectum,  intestine, 
and  uterus  they  are  pedunculated.  A  single  adenoma  may  be 
present,  but  two  or  more  may  exist  in  the  same  gland.  In 
the  case  of  the  intestine  a  score  or  more  may  grow  in  the 
same  individual.  In  size  they  vary  greatly :  some  are  no 
larger  than  peas,  whereas  in  the  mamma  an  adenoma  will 
occasionally  attain  the  dimensions  of  a  man's  head. 

The  effects  of  adenomas  depend  mainly  upon  the  situations 
in  which  they  grow.  The  following  statements  are  true  for 
all :  When  completely  removed  there  is  no  recurrence ;  they 
do  not  infect  neighbouring  lymph- glands,  nor  give  rise  to 
secondary  deposits.  When  an  adenoma  causes  death,  it  is 
in  consequence  of  mechanical  complications,  depending  on 
the  situation  and  size  of  the  tumour. 

Although  the  distinguishing  structural  peculiarity  of  an 
adenoma  is  the  presence  of  epithelium  disposed  as  in  a  secret- 
ing gland,  the  connective  tissue  (stroma)  entering  into  its 
composition  must  also  be  taken  into  account.  In  many 
adenomas  the  epithehal  element  is  the  most  conspicuous ;  in 
others  the  connective  tissue  is  out  of  all  proportion  to  the 
epithelium,  and  occasionally  preponderates  to  such  a  degree 
that  the  tumour  from  some  writers  receives  the  misleading 
name  of  "  adeno-sarcoma."  When  the  epithelium-lined  spaces 
are  distended  with  fluid,  the  tumour  is  termed  a  cystic 
adenoma  (adenocele).  The  source  of  this  fluid  is  of  some 
interest,  because  adenomas  are  similar  in  structure  to  the 
gland  in  which  they  arise  (Fig.  146),  yet  they  are  unable  to 

248 


ADENOMA   OF  MAMMA 


249 


furnish  the  secretion  pecuhar  to  the  gland.  In  the  case  of 
adenomas  growing  from  mucous  membrane — e.g.  the  rectal 
and  uterine  adenomas — the  glandular  pits  furnish  a  per- 
verted secretion. 

In  the  case  of  the  thyroid  gland,  the  adenoma  is  so  en- 
capsuled  that  the  secretion  furnished  by  the  gland-tissue  of 
the  tumour  cannot  escape,  and,  slowly  accumulating,  converts 


a^a"=S^' 


Fig.  146. — Section  of  an  adenoma  from  a  cMld's  rectum.     {Highly  magnified.) 

the  adenoma  into  a  cyst.  This  occurs  also  in  the  mamma  ; 
but  it  will  be  shown  in  connexion  with  adenomas  of  this 
gland  that  the  fluid  sometimes  escapes  by  the  natural  duct. 

Adenomas  may  arise  at  any  point  in  the  mucous  mem- 
brane of  the  gastro-intestinal  tract,  and  they  do  not,  as  a  rule, 
attain  big  dimensions.  The  adenoma  that  Lexer  removed 
from  the  stomach  of  an  adult,  which  was  as  big  as  a  child's 
head,  is  very  exceptional ;  it  grew,  by  a  stalk  as  thick  as  two 
fingers,  from  the  gastric  mucous  membrane  near  the  pylorus. 

Adenomas  exhibit  pecuhar  characters,  and  occasion  dis- 
turbances which  vary  with  the  gland  in  which  they  arise; 


250 


EPITHELIAL   TUMOURS 


it  will  therefore  be  convenient  to  consider  each  variety 
separately.  It  will  be  useful  to  point  out  that  although 
adenoma  and  carcinoma  may,  and  often  do,  co-exist  in  the 
same  gland,  an  adenoma  never  becomes  transformed  into 
cancer. 

The  best-known  instance  of  the  combination  of  an  adenoma 
and  carcinoma  in  the  same  gland  was  observed  by  Hutchinson. 


Carcinoma. 


Adenoma. 


Fig.  147. — Mamma  in  section ;  it  contains  a  fibro-adenoma  surrounded  by  cancer. 
{3Iuseum,  Royal  College  of  Surgeons. ) 

In  this  instance  the  adenoma  was  embedded  in  a  mammary 
carcinoma  (Fig,  147),  and  the  patient,  a  woman  46  years  of 
age,  had  been  aware  of  the  existence  of  a  tumour  for  twenty 
years. 

Adenoma  of  the  mamma. — There  are  two  varieties  of 
mammary  adenoma  :  1,  fibro-adenoma  ;  2,  cystic  adenoma. 

1.  Fibro-adenomas. —  These  occur  as  spherical  or  oval 
tumours  furnished  with  capsules,  lodged  in  the  superficial 
parts  of  mammae ;  exceptionally  they  may  be  situated  deeply 
in  the  breast  substance.     As  a  rule,  they  are  firm  and  elastic 


Adenoma  of  mamma 


2hl 


to  the  touch,  and  shp  about  under  the  examining  finger. 
It  is  not  rare  to  find  a  fibro-adenoma  in  each  mamma,  nor 
is  it  unusual  to  find  more  than  one  tumour  in  the  same 
gland.  When  occupying  a  superficial  position  they  will, 
even  when  small,  project  the  skin  so  as  to  cause  an  irregu- 
larity in  the  contour  of  the  breast ;  very  exceptionally 
they  may  be  pedunculated.  Although  the  majority  of  mam- 
mary adenomas  do  not  exceed  the  dimensions  of  a  walnut 
or  of  a  Tangerine  orange,  some  are  as  big  as  coco-nuts. 


Fig.  148. — Cystic  adenoma  with  a  glandular  process.     The  cyst  communicated  with 
a  duct  in  the  nipple. 

Structurally  they  consist  of  fibrous  tissue  in  which 
glandular  acini  are  embedded ;  the  tumour  itself  is  isolated 
from  the  surrounding  gland-tissue  by  a  definite  capsule. 

Tumours  of  this  character  are  commonly  met  with  in  the 
years  succeeding  puberty.  It  is  rare  to  meet  with  them 
before  the  age  of  15,  but  Patteson  has  published  a  care- 
ful description  of  two  cases  met  with  in  girls  of  13 
years.  These  are  probably  the  youngest  cases  yet  recorded. 
The  great  rarity  of  fibro-adenomas  of  the  breast  before 
puberty  is  due  to  the  simple  construction  of  the  breast   in 


252 


EPITHELIAL   TUMOURS 


the  non-pubic  girl.  The  gland-elements  are  represented  by 
epithelium-lined  tubes,  which  branch  slightly,  embedded  in 
fibrous  tissue.  After  puberty  the  gland-elements  multiply, 
and  this  activity  is  accompanied  by  a  corresponding  active 
growth  of  the  fibrous  tissue  in  the  breast. 

2.  Cystic  adenomas. — As  women  increase  in  age,  and 
especially  if  the  breast  has  an  opportunity  of  fulfilling*  its 
function,  then  adenomas  which  arise  in  the  gland   contain 


Fig.  149. — Dilated  galactophorous  duct  with  intracystic  growth. 

much  more  epithelium  and  far  less  connective  tissue.  The 
epithelial  cells  are  larger,  and  approach  in  character  those  of 
the  active  mamma.  Adenomas  of  this  kind  form  far  larger 
tumours  than  those  to  which  the  term  fibro-adenoma  is  usually 
applied.  Occasionally  the  glandular  acini  become  dilated  with 
fluid  and  form  cystic  spaces ;  the  tumour  is  then  termed  a 
cystic  adenoma  (or  an  adenocele).  At  times  a  cyst  of  this 
kind  will  retain  its  communication  with  the  galactophorous 
duct  (Fig.  148),  and  the  secretion  will  sometimes  escape  at 
the  nipple.     Indeed,  it  is  possible,  when  examining  a  breast, 


ADENOMA    OF  MAMMA  253 

b"y  gently  squeezing  the  tumour  to  force  a  jet  of  fluid 
through  the  nipple.  This  is  a  diagnostic  sign  of  great 
value.  It  sometimes  happens  after  removal  of  a  large  cyst 
of  this  kind  that  a  bristle  can  be  passed  from  the  cyst  along 
a  galactophorous  duct.  In  some  adenomas  the  cystic  por- 
tion largely  preponderates,  the  glandular  element  merely  pro- 
jecting as  a  bud  into  the  cyst.  A  sha,rp  distinction,  however, 
must  be  drawn  between  a  cystic  adenoma  and  a  dilatation  of 
a  galactophorous  duct  with  intracystic  growth  (Fig.  149). 
This  variety  is  closely  allied  to  duct-cancer  and  duct-papil- 
loma.  Cystic  dilatation  of  a  galactophorous  duct  during 
lactation  is  known  as  a  galactocele. 

Some  of  the  rarer  but  larger  and  more  formidable  kinds 
of  mammary  adenomas  are  those  which  combine  all  the 
characters  of  the  preceding  varieties.  That  is,  they  con- 
tain much  fibrous  tissue,  and  numerous  and  fairly  large  cystic 
spaces,  many  of  which  are  also  almost  completely  occupied 
by  intracystic  processes.  Mammary  tumours  of  this  kind 
sometimes  attain  very  large  proportions,  weighing  upwards  of 
five  or  even  ten  pounds.  These  tumours  have  received  a 
variety  of  denominations,  such  as  sero-cystic  tumours,  adeno- 
sarcomas,  and  so  on.  However,  clinically  they  are  quite  in- 
nocent, and  do  not  recur  after  removal. 

It  is  a  remarkable  thing  to  remove  a  large  complex  ade- 
noma of  this  kind  and  to  find  it  completely  encapsuled,  whilst 
the  breast  lies  like  a  small  process  quite  isolated  from  the 
tumour. 

The  description  of  adenoma  of  other  organs  will  be  found 
in  the  succeeding  chapters. 

Hutchinson,  Sir  J.,  "  Adenoma  Mamm£e,  Supervention  of  Scirrhus." — Trans. 
Path.  Soc,  xxxix.  319. 

Lexer,  Lelirhucli  der  allgemeinen  Chir.,  1905,  ii.  371. 

Patteson,  "Adenoma  of  the  Breast  in  Childhood." — Journ.  of  Anat.  and  Phys., 
1892,  xxvi..  509. 


CHAPTER    XXV 

CARCINOMA    (CANCER) 

This  term,  in  the  strict  sense  in  which  it  is  used  by  patholo- 
gists, signifies  a  malignant  tumour  arising  in  epithelium. 
The  disease  is  of  very  great  importance  on  account  of  its 
insidious  onset,  and,  in  the  earliest  stages,  painlessness ; 
its  progressive  and  irresistible  destructiveness ;  the  manner 
in  which  it  infects  lymph-glands ;  the  extraordinary  effects 
produced  in  different  organs  on  account  of  the  dissemination 
of  the  growth  in  the  form  of  secondary  nodules;  the  helpless- 
ness, misery,  and  pain  it  produces  when  fully  advanced ;  and 
the  inability  of  medical  and  surgical  art  to  deal  effectively 
with  it,  save  in  the  earliest  stages.  Although  this  disease 
was  recognized  in  the  dawn  of  medicine,  we  not  only  remain 
ignorant  of  its  cause,  but,  in  many  instances,  the  diagnosis 
of  the  malady  is  uncertain  in  the  living.  This  is  not  due  to 
supineness  on  the  part  of  investigators,  but  to  the  absence 
of  what  is  called  "  specific  symptomatology." 

Varieties  of  cancer. — Epithelium  plays  two  parts  in  the 
animal  economy :  protective,  as  on  the  skin ;  and  secretory, 
where  it  is  found  in  glands.  When  carcinoma  arises  from 
a  surface  covered  with  epithelium  of  the  protective  variety 
it  is  called  squamous-celled  cancer  ;  and  when  it  arises  in  the 
epithelium  of  glands  it  is  termed  glandular  cancer. 

The  microscopic  structure  of  a  carcinoma  is  very  simple 
and  consists  of  columns  of  cells,  so  that  when  the  columns 
are  cut  at  right  angles  the  section  has  the  appearance 
of  a  number  of  alveolar  spaces  filled  with  epithelium. 
The  walls  of  these  alveoh  are  composed  of  fibrous 
tissue,  presenting  various  degrees  of  density,  in  which 
blood-  and  lymph-vessels  ramify.  The  cell- columns  are  not 
always  simple,  but  may  branch  in  various  directions,  and 
thus    produce    in   some    sections   very   complicated   appear- 

254 


8QUAM0US-GELLED    GANGER  255 

ances,  the  softness  or  hardness  of  the  cancer  depending  on 
the  amount  of  fibrous  tissue  between  the  cokimns  of  cells. 
This  plan  of  structure  underlies  all  the  varieties  of  malig- 
nant epithelial  tumours,  even  those  which  arise  on  surfaces 
covered  with  squamous  epithelium.  The  cells  composing 
the  columns  depend  upon  the  character  of  the  epithelium 
in  which  the  cancer  originates,  and  this  feature  is  so  striking 
that  the  histologist  can  often  pronounce  with  certainty  the 
particular  gland  in  which  a  cancer  arose,  merely  from  study- 
ing a  carefully  prepared  specimen  under  the  microscope. 

Stroma  and  parenchyma. — Every  tumour,  whether  it  be 
innocent  or  malignant,  except  the  chorion-epithelioma  (Chap. 
XL.),  presents  a  stroma  and  a  parenchyma.  These  two  ele- 
ments are  particularly  observable  in  adenomas  and  carcinomas 
on  account  of  the  striking  difference  in  the  characters  of  the 
connective  tissue  and  the  epithelium.  In  the  case  of  carci- 
noma, as  the  epithelial  cells  multiply  and  intrude  into  the 
adjacent  tissue,  the  intrusion  is  answered  by  a  formation  of 
tibrous  tissue:  this  response  is  less  marked  in  the  rapidly 
growing  tumours  than  in  those  which  grow  slowly.  This 
response  of  the  tissues  to  irritation  has  been  termed  the 
specific  tissue-reaction,  but  it  is  as  obvious  in  many  of  the 
common  forms  of  tissue-irritants,  such  as  micro-organisms, 
and  especially  foreign  bodies.  Some  of  the  most  striking 
examples  of  the  formation  of  fibrous-tissue  capsules  in 
response  to  irritation  are  those  which  form  around  an  echi- 
nococcus-cyst  lodged  in  the  great  omentum.  In  the  case 
of  a  sarcoma  a  kind  of  investment  is  furnished  for  each 
cell,  but  in  a  carcinoma  the  cells  are  invested  in  groups  pro- 
ducing in  reality  a  fibrous-tissue   maze. 

Squamous-celled  cancer. — This  may  arise  on  any  surface 
covered  with  stratified  epithelium,  but  it  is  more  common 
in  situations  where  there  is  a  transition  from  one  kind  of 
epithelium  to  another,  and  especially  where  skin  and  mucous 
membrane  come  in  relation — e.g.  the  anus,  vulva,  or  lip. 

It  may  make  its  appearance  as  a  wart-like  growth, 
more  frequently  as  a  small  circular  ulcer  with  raised  ram- 
part-like edges,  or  as  a  fissure,  and  it  is  particularly  apt  to 
arise  on  the  scrotum  of  the  chimney-sweep  (Chap.  xxxv.). 

Sweep's     cancer    usually    begins    as     a    wart    which    is 


256 


EPITHELIAL   TUMOURS 


familiarly  known  as  a  "  soot  -  wart."  A  similar  form  of 
cancer  is  described  as  arising  in  men  who  work  in  tar, 
paraffin,  and  pitch.  This  matter  has  been  investigated 
by  Legge. 

Although  the  three  clinical  varieties  of  sqiiamous-celled 
cancer  look  so  different,  they  are  identical  in  structure. 
When  sections  are  cut  so  as  to  include  the  margin  of 
the  ulcer  and  underlying  tissue,  the  surface-epithelium 
will  be   seen   invading  it  in  the  form   of  long,    simple,    or 

ramified  columns.  When  the  cones 
grow  rapidly,  the  cells  become  flat- 
tened, and  some  finally  cornify.  In 
this  way  the  so-called  epithelial 
pearls  or  nests  are  produced.  When 
lateral  pressure  is  made  on  a  fresh 
specimen,  whitish  plugs  are  forced 
out;  these  plugs  are  the  cellular 
cones. 

It  is  important  to  bear  in  mind 
that  the  three  clinical  varieties  of 
squamous  -  celled  cancer  occur  in 
most  of  the  situations  liable  to  this 
disease,  such  as  the  lips,  tongue, 
cheeks,  vulva,  and  glans  penis.  This 
disease  is  occasionally  met  with  in 
the  urethra,  the  pinna,  and  in  the  conjunctiva,  especially  when 
it  has  been  injured  by  lime.  Examples  of  squamous-celled 
cancer  of  the  pinna  have  been  described  by  Hulke,  Bowlby, 
and  Williams. 

Cancers  in  the  scars  of  burns. — It  has  long  been  known 
that  chronic  ulcers  of  all  kinds  are  liable  to  become  the 
seat  of  cancer.  This  is  true  also  of  the  scars  left  by  burns, 
and  especially  of  the  chronic  ulcers  so  common  along  the 
edges  of  the  scar  left  by  an  extensive  burn. 

An  interesting  contribution  to  this  matter  we  owe  to 
Neve.  During  twenty  years  4,902  tumours  have  been 
removed  at  the  Kashmir  Mission  Hospital.  Among  this 
number  1,720  were  malignant ;  1,189  of  the  malignant 
tumours  Avere  classed  as  carcinomatous,  of  which  848  arose 
on  thighs  or  abdomen.     The  cancer  arises  in  ulcers  caused  by 


Fig.  150. — Section  of  an  epithe 
Hal  cone.     {Magnified.') 


GANGER  257 

burns  from  the  use  of  the  kangri,  a  portable  fire-basket.  The 
kangri  is  suspended  round  the  waist  under  the  flowing  robes 
of  the  natives  of  the  cold  hills  of  Kashmir  (-Fig.  151).  In 
many  instances  the  carcinoma  arises  in  scar-tissue.  The  use 
of  the  kangri  by  the  Kashmiri  is  akin  to  that  of  the  chauf- 
ferette  by  poor  old  folk  in  France  (p.  246). 

X-ray  cancer. — Since  the  X-rays  have  been  employed  for 
the    detection    and    cure    of    certain    diseases,    it    has   been 


Fig.  151. — A  group  of  Kashmii'i  with  the  portable  fire-baskets  known 
as  kangri.     {After  E.  F.  Neve,  Brit.  Med.  Journ.,   1910,  ii.  589.) 

discovered  that  they  sometimes  produce  changes  in  the 
skin  known  as  X-ray  burns,  or  X-ray  dermatitis,  which  are 
extremely  difficult  to  treat  and  in  some  instances  become 
cancerous. 

The  alterations  in  the  skin  covered  by  the  term  X-ray 
dermatitis  may  affect  not  only  those  who  receive  the  rays 
designedly  for  the  cure  of  local  disease  but  also  those  who 
apply  them,  and  the  latter  appear  to  be  the  greater  sufferers. 
The  earliest  changes  consist  of  an  erythema  around  the 
base  of  the  nails,  which  become  brittle  and  degenerate  into 
shapeless  masses.  The  skin  reddens  and  small  warts  appear ; 
11 


258  EPITHELIAL   TUMOURS 

cracks  and  ulcerated  patches  occur  and  refuse  to  heal.  The 
ulcers  and  cracks  are,  extremely  painful,  and  in  a  small 
proportion  of  cases  become  malignant.  Whilst  these  changes 
are  progressing  in  the  skin,  the  deeper  tissues  undergo 
nutritional  changes  and  the  bones  of  the  fingers  waste. 

Eowntree,  who  has  had  opportunities  of  studying  the  path- 
ology of  several  cases  of  X-ray  cancer,  states  that  the  growth 
has  all  the  typical  features  of  squamous-celled  carcinoma, 
cell-nest  formation  being  well  marked.  The  precancerous 
stage — the  stage  of  chronic  dermatitis — is  prolonged,  and 
the  transition  to  carcinoma  is  effected  by  slow  and  insensible 
gradations. 

X-ray  cancer  is  of  low  malignancy  and  only  occasionally 
infects  the  lymph-nodes  ;  metastasis  is  unusual.  The  only 
available  treatment  is  amputation  of  the  affected  fingers,  or 
the  hand.     Recurrence  is  unusual. 

Rowntree  states  that  since  the  introduction  of  X-ray 
treatment  for  lupoid  ulcers  the  percentage  of  cases  in  which 
such  ulcers  have  become  carcinomatous  has  materially  in- 
creased. 

Local  changes  which  clinical  observation  has  shown  to 
precede  cancer  are  termed  precancerous  conditions. 

A  squamous-celled  cancer,  Avhen  left  to  follow  its  own 
course,  may  extend  and  involve  extensive  tracts  of  tissue,  or 
fungate  and  form  huge  granulating  dendritic  masses.  In 
both  cases  the  superficial  parts  are  continually  cast  off  in 
a  foul,  fetid  discharge  containing  sloughs  of  tissue,  cellular 
detritus,  and  blood.  Vascular  tissues,  such  as  skin,  muscle, 
and  mucous  membrane,  are  quickly  infiltrated  and  destroyed ; 
even  bone  is  rapidly  eroded.  Cartilage  resists  invasion  ;  this 
is  seen  in  a  striking  way  in  those  rare  instances  in  which 
cancer  attacks  the  pinna ;  the  skin  and  soft  tissues  quicldy 
disappear,  whilst  its  cartilaginous  framework  stands  promi- 
nently out  amidst  the  surrounding  ruin. 

In  whatever  situation  squamous-celled  cancer  occurs,  it 
destroys  life  rapidly.  The  quickness  with  which  it  ulcerates 
and  overcomes  all  resistance  enables  it  to  open  large  blood- 
vessels should  any  lie  in  its  way  ;  hence  death  from  haemor- 
rhage is  frequent.  When  the  cancer  is  near  the  air-passages, 
oul  material  is  inspired  and  initiates  septic  pneumonia. 


GLAND-GANGEB  259 

Gland-cancer. — This  variety  arises  in  the  epithelium  of 
secreting  glands ;  it  is  exceedingly  common  in  some  and  rare 
in  others,  so  it  will  be  convenient  to  discuss  the  liability  of 
the  various  glands  separately ;  but  the  general  features  of  this 
disease  are  the  same  in  whatever  gland  it  arises. 

A  striking  feature  of  cancer  is  the  fact  that  it  does  not 
form  a  circumscribed  tumour.  When  examined  clinically  it 
is  rarely  possible  to  define  the  limits  between  the  tumour 
and  the  surrounding  tissues,  and  this  indefiniteness  is  more 
obvious  when,  in  the  course  of  an  operation,  the  surgeon 
cuts  into  it ;  but,  what  is  more  significant,  when  the  peri- 
phery of  a  cancer  is  subjected  to  microscopic  scrutiny  the 
eye  of  a  competent  pathological  histologist  is  unable  to  discern 
the  precise  limitation  of  the  cancerous  territory. 

This  illimitation  of  cancer  constitutes  one  of  the  greatest 
obstacles  in  dealing  with  it  surgically  ;  for  if  with  the  aid  of 
a  microscope  there  is  difficulty  in  defining  its  limits,  how 
uncertain  the  surgeon  must  be  in  determining  its  extent 
with  only  fingers  and  eyes  to  guide  him  during  an  operation  ! 
This  has  led  to  the  practice,  in  recent  years,  of  complete  ex- 
tirpation, whenever  possible,  of  cancerous  organs.  Although  a 
cancer  is  for  a  time  limited  to  the  gland  in  which  it  arises, 
we  have  no  means  of  distinguishing  with  any  reasonable 
certainty,  when  the  individual  comes  under  observation,  that 
the  cancer  is  limited  to  the  gland,  for  its  outrunners  quickly 
involve  surrounding  structures,  whether  skin,  fat,  mucous 
membrane,  muscle,  or  bone.  When  adjacent  parts  are 
infiltrated  or  permeated  in  this  way,  it  is  convenient  to 
describe  them  as  being  implicated  in  the  cancer.  This 
implication  of  organs  is  a  grave  feature,  and  a  common  cause 
of  death,  and  it  is  often  a  bar  to  operative  intervention. 

The  insidious  way  in  which  fascia  is  permeated  by 
carcinoma  has  recently  been  made  the  subject  of  a  careful 
investigation  by  Handley  (see  p.  269). 

Although  cancers,  like  all  epithelial  structures,  are  in 
free  communication  with  the  lymph-system,  they  are  poorly 
supplied  with  blood :  this  leads  to  retrograde  changes,  which 
it  is  customary  to  describe  as  degeneration.  The  commonest 
of  these  is  known  as  colloid  degeneration,  in  which  the  epi- 
thelium in  the  cell-columns  becomes  changed  into  a  structure 


260  EPITHELIAL   TUMOURS 

less  material  resembling  jelly:  this  change  is  particularly 
common  in  cancer  of  the  stomach  and  colon.  It  is  well 
known  that  a  primary  cancerous  lesion  may  undergo  retro- 
gressive changes  and  almost  disappear.  The  variety  known 
as  "  withering  cancer  "  or  "  atrophic  cancer  "  of  the  breast  is 
an  example  of  this.  Patients  with  this  kind  of  cancer  have 
lived  ten,  fifteen,  and  even  twenty  years.  The  not  un- 
common form  of  cancer  found  in  the  colon,  especially  in  the 
sigmoid  flexure,  where  the  growth  encircles  and  narrows  the 
gut  so  tightly  that  it  seems  as  if  a  piece  of  cord  were  tied 
around  it,  is  really  a  primary  carcinoma  undergoing  sponta- 
neous cure;  but  it  surely  destroys  life,  if  not  from  its 
mechanical  effect  in  obstructing  the  colon,  by  infecting  the 
liver  and  peritoneum. 

Thus  cancer  manifests  itself  differently  in  the  same  organ, 
and  its  effects  vary  more  widely  in  diverse  organs.  For 
example,  primary  cancer  of  the  liver  is  always  massive,  and 
leads  sometimes  to  enormous  enlargement  of  this  organ. 
This  is  also  true  of  secondary  deposits  in  the  liver,  for  they 
attain  a  greater  size  in  its  tissues  than  elsewhere.  Hillier 
suggests  that,  in  addition  to  the  large  size  of  the  liver,  its 
small  proportion  of  connective  tissue,  its  blood-supply,  copious 
•  and  rich  with  food  products,  may  explain  this ;  carcinomatous 
growths  contain  a  large  amount  of  glycogen,  and  its  presence 
in  the  hepatic  cells  may  have  something  to  do  with  the  way 
in  which  cancer  flourishes  in  the  liver.  Secondary  (or  im- 
plantation) cancer  of  the  ovary  sometimes  forms  masses  as 
big  as  a  man's  head.  This  exuberant  growth  probably 
depends  on  the  abundant  blood-supply  of  the  ovary  and  the 
exclusion  of  pathogenic  micro-organisms. 

Primary  cancer  of  the  pancreas  seldom  forms  a  large  mass, 
and  usually  appears  in  the  head  of  the  gland  as  an  ill-defined 
swelling. 

The  difference  in  the  proportion  of  fibrous  tissue  in  the 
liver  and  in  the  pancreas  may  offer  some  explanation  of  the 
variation  of  size  in  cancerous  masses  in  the  two  organs. 

Infection  of  lymph-glands. — The  surfaces  of  our  bodies, 
whether  skin  or  mucous  membrane,  are  rich  in  lymphatics, 
and  as  the  secreting  glands  are  primarily  derived  from  these 
surfaces,  it  naturally  comes  about  that  they  are  in  free  com- 


LYMPH- GLAND  INFECTION  261 

munication  with  the  lymphatics  and  lymph-glands  or  lymph- 
nodes.  The  lymphatics  involved  in  the  cancerous  material 
convey  the  cancer  elements  to  the  lymph-glands,  and  these 
may  become  so  surcharged  as  to  burst  their  capsules.  Lymph- 
glands  enlarged  in  this  way  sometimes  form  very  con- 
siderable masses,  and  it  is  not  uncommon  to  find  a  primary 
carcinoma  with  a  diameter  of  2  cm.  associated  with  a 
collection  of  lymph-glands  as  big  as  a  fist.  Lymph-gland 
infection  varies  in  rapidity  and  degree ;  great  differences 
occur  not  only  in  regard  to  cancer  of  particular  organs,  but 
also  in  relation  to  the  same  organ  in  different  individuals. 
Sometimes  lymphatic  channels  are  so  stuffed  with  cancer- 
ous material  that  they  may  be  dissected  from  the  connective 
tissue  and  traced  to  the  lymph-gland. 

When  cancer  arises  in  lupus-scars  the  adjacent  lymph- 
nodes  are  unaffected.  This  is  attributed  to  the  previous 
destruction  of  the  lymphatics  by  the  lupus  (Wild). 

Occasionally  the  ducts  from  the  lymph-glands  about  the 
receptaculum  chyli,  the  receptaculum  itself,  and  the  thoracic 
duct  are  stuffed  with  cancerous  material  (Fig.  152). 

The  relation  of  the  growth  to  the  wall  of  the  duct  shows 
that  the  implication  of  its  structures  is  complete ;  it  is  not 
due  to  the  mere  blocking  of  its  lumen  with  cancerous  tissue, 
resembling  the  clot  in  a  thrombosed  vein,  but  its  walls  are 
infiltrated  with  the  cancerous  tissue  in  the  way  that  sarco- 
matous tumours  implicate  the  walls  of  large  veins. 

Obstruction  of  the  thoracic  duct  by  extension  of  cancer 
has  been  noticed  in  association  with  primary  cancer  of  the 
stomach,  uterus,  rectum  ;  and  careful  descriptions  of  the  con- 
ditions have  been  published  by  Unger,  Weigert,  Troisier,  and 
Hillier,  among  others.  Perhaps  the  most  remarkable  feature 
of  the  complication  is  the  absence  of  any  indication  that 
this  duct  was  obstructed,  and  in  no  case  was  chylous  ascites 
observed.  The  implication  of  the  thoracic  duct  in  cancer 
of  the  stomach  explains  the  enlargement  of  the  lymph-glands 
at  the  root  of  the  neck  ;  this  is  a  sign  of  diagnostic  value. 

The  extent  to  which  lymphatic  infection  has  occurred  is 
a  matter  which  cannot  be  accurately  defined  in  a  given 
case  of  carcinoma,  and  this  adds  an  additional  factor  of 
uncertainty  in  estimating  the  results  and  value  of  surgical 


^  ll"l,'l'jiill    ^ 


Fig.  152. — Thoracic  duct  and  receptaculum,  with  some  adjacent  glands,  stuffed 
with  cancerous  material  secondary  to  cancer  of  the  rectum.     {Sillier.) 

262 


DISSEMINATION  263 

procedure.  Lymph-gland  infection  is  always  an  element  of 
danger.  When  the  cervical  glands  are  enlarged  they  inter- 
fere with  the  trachea  and  oesophagus ;  they  also  become 
firmly  adherent  to  the  sheaths  of  big  vessels,  and,  as  the 
glands  break  down,  the  ulcer  opens  up  the  jugular  vein,  or 
the  carotid  artery,  while,  in  the  inguinal  region,  the  femoral 
vessels  are  eroded.  Lymph  -  glands,  when  enlarged  and 
stuffed  with  carcinomatous  cells,  have  a  great  tendency  to 
soften  in  the  centre  and  form  spurious  cysts.  When  the  skin 
becomes  implicated,  extensive  portions  of  the  infected  glands 
slough,  and  leave  large,  horrible  holes,  from  which  a  fetid 
fluid  issues,  whilst  the  edges  of  the  chasm  produced  by  the 
sloughing  continue  to  extend  and  involve  the  neighbouring 
tissues. 

The  size  of  the  cancerous  mass,  produced  by  the  infected 
lymph-glands  and  the  tissue  infected  by  them  when  they 
become  so  stuffed  with  cancer  that  they  burst  their  capsules,  is 
often,  as  has  already  been  mentioned,  out  of  all  proportion 
to  the  initial  lesion ;  indeed,  in  many  instances  the  patients 
are  little  troubled  by  the  primary  ulcer,  which  may  be  so 
small  and  inconspicuous  as  to  escape  observation  until  the 
enlargement  of  the  lymph-glands  compels  them  to  seek  advice, 
which  leads  to  a  search  for  the  primary  lesion. 

It  is  not  uncommon  when  this  focus  is  situated  in  a  recess 
in  the  mouth  or  pharynx  for  the  cancerous  ulcer  to  be  so  small 
as  to  be  completely  overlooked,  and  then  the  cancerous  gland- 
mass  in  the  neck  is  supposed  to  arise  in  epithelial  vestiges  of 
the  branchial  folds.  It  is  also  possible  that  the  primary  focus 
undergoes  retrogressive  changes  and  heals  spontaneously,  while 
the  gland-infection  proceeds  to  the  patient's  destruction. 

Dissemination. — Cancers  are  extremely  prone  to  dissemi- 
nation, which  means  the  formation  of  secondary  growths 
resulting  from  the  deportation  of  minute  fragments  of  cancer 
(cancer  emboli),  which  may  lodge  in  any  organ  or  tissue. 
The  cells  which  give  rise  to  secondary  nodules  are  transported 
by  lymph-  and  blood-vessels,  and  by  an  insidious  process 
known  as  permeation.  When  these  minute  emboli  and  cancer 
particles  lodge  in  suitable  positions  they  multiply,  giving  rise 
to  a  growth  which  in  its  histologic  features  exactly  resembles 
the  parent  tumour.     So  faithful  is  this  reproduction  that  the 


264  EPITHELIAL   TUMOURS 

nature  of  the  primary  tumour  can  often  be  correctly  interred 
from  a  microscopic  examination  of  a  secondary  nodule. 

The  amount  of  dissemination  varies  greatly.  In  some 
cases  secondar}^  deposits  will  be  found  only  in  the  liver, 
whilst  in  another  and  apparently  identical  case,  in  so  far  as 
the  structure  of  the  tumour  is  concerned,  secondary  knots 
occur  in  almost  every  organ  of  the  bodj^  including  the  skeleton. 
In  the  case  of  squamous-celled  cancer  it  cannot  be  said  that 
secondary  deposits  are  rare,  but  dissemination  certainly 
happens  far  less  frequently,  and  never  so  extensively  as  in 
cancer  arising  in  secreting  glands.  It  is  also  noteworthy  that 
the  squamous-celled  variety  is  in  some  situations  more 
liable  to  disseminate  than  in  others.  For  example,  secondary 
deposits  are  rarely  met  with  when  this  disease  attacks  the 
larynx,  or  the  mucous  membrane  in  relation  with  the 
mandible  or  maxill&e,  or  the  oesophagus.  The  explanation 
sometimes  offered  of  this  peculiarity  is  that  carcinoma  in 
these  situations  usually  runs  a  rapid  course,  and  often  destroys 
life  so  quickly  that  the  period  is  too  short  to  allow  of  the 
formation  of  secondary  nodules.  This  is  inadmissible,  for  in 
cancer  of  the  scrotum  dissemination  is  almost  as  exceptional 
as  when  the  larjmx  is  attacked. 

Secondary  deposits  of  cancers  are  not  always  so  small  as 
merely  to  merit  the  name  of  knots,  but  form  occasionally 
tumours  of  some  magnitude. 

The  vitality  and  power  of  independent  growth  possessed 
by  cancer  emboli  is  very  remarkable.  These  minute  epithelial 
emigrants  not  only  live  and  grow,  but  reproduce  the  pecu- 
liarity of  the  primary  cancer.  It  is  astonishing  to  find  a 
secondary  cancerous  deposit  in  the  humerus  with  all  the 
characters  of  the  s^lands  of  the  rectum :  a  multitude  of 
secondary  nodules  in  the  skin  with  the  structural  features  of 
gastric  glands ;  nodules  in  the  lungs  exactly  reproducing  that 
peculiar  form  of  hepatic  carcinoma  which  arises  in  the  biliary 
ducts  ;  the  familiar  closed  follicles  of  the  thyroid  gland  repro- 
duced in  the  body  or  spinous  process  of  a  vertebra ;  nodules 
resembling  the  structure  of  mammary  carcinoma  in  the  ovary, 
brain,  or  choroid  coat  of  the  eye ;  and  a  mass  growing  from 
the  frontal  bone  with  all  the  characters  of  the  prostate  gland, 
secondary  to  cancer  of  that  organ.     It  is  one  of  the  great 


BIS  SEMINATION 


265 


triumphs  of  pathological  histology  that  it  has  demonstrated 
that  carcinoma  takes  its  type  of  epithelium  from  the  secreting 
gland  in  which  it  arises. 

This  power  of  independent  growth  possessed  by  the  epithe- 
lium of  cancer  is  a  very  dangerous  feature,  and  does  not 
always  need  blood-  or  lymph- vessels  for  its  manifestation.     It 


X  130 


Fig.   153. — Section  through  a  portion  of  an  inguinal   lymph-gland  infected  with 
cancer :  the  primary  disease  was  in  the  rectum.     (After  Foulerfon. ) 

sometimes  happens  that  an  abdominal  viscus  is  attacked  by 
cancer,  and  a  small  outgrowth  makes  its  way  through  the 
peritoneal  covering  and  bursts,  and  sheds  its  cells  into  the 
general  peritoneal  cavity ;  these  are  distributed  by  the  peri- 
toneal fluid  and  the  movements  of  the  bowels,  and  in  a  few 
weeks  the  whole  of  the  serous  membrane  will  be  dotted  with 
hundreds,  and  sometimes  thousands,  of  nodules,  each  repro- 
ducing the  type  of  the  parent  tumour.  This  mode  of  epithe- 
lial infection  of  the  peritoneum  I  have  found  in  cancer  of 
the  gall-bladder,  ovary,  and  especially  in  cancer  of  the  body 
of  the  uterus;  no  form  of  dissemination  gives  rise  to  such 


266  EPITHELIAL    TUMOURS 

innumerable  secondary  nodules  as  this,  nor  demonstrates  in 
a  more  remarkable  way  the  power  of  epithelium  to  engraft 
itself,  to  live,  and  to  grow.  All  cancer-cells  which  fall  on  the 
peritoneum  do  not  live  in  spite  of  their  vitality,  for  this 
membrane  has  the  power  of  destroying  them.  Many  which 
grow  are  hindered  from  doing  much  harm,  for  they  become 
encysted.  Implanted  cancer  flourishes  best  on  connective 
tissue  {see  Cancer  Infection,  p.   270). 

Secondary  deposits  of  cancer  may  occur  in  any  organ  and 
tissue  of  the  body;  my  own  observations  teach  me  that 
among  the  malignant  epithelial  tumours,  cancers  of  the  breast 
and  of  the  pylorus  give  rise  to  the  wadest  form  of  dissemina- 
tion. Thus  cancer  is  very  infectious  to  the  individual  affected 
with  cancer,  but  not  to  others.  The  rarest  of  all  tissues  in 
which  to  find  secondary  deposits  is  voluntary  muscle,  and  the 
rarest  of  all  organs  is  the  heart.  Secondary  deposits  are  even 
met  with  in  the  eyeball,  and  it  is  a  curious  fact  that  the 
great  majority  of  cases  occur  in  association  with  mammary 
cancer,  and  in  one  exceptional  case  both  eyeballs  con- 
tained secondary  nodules.  Secondary  deposits  in  the 
S'lobe  have  also  been  observed  in  connexion  with  cancer 
of  the  stomach  and  thyroid  gland.  (Rowan  and  Devereux 
Marshall. ) 

Secondary  cancer  of  the  lung. — The  extraordinary  frequency 
with  which  the  lung  is  infected  with  malignant  disease, 
whether  sarcoma  or  carcinoma,  is  due  to  the  circulation. 
In  the  case  of  sarcoma  the  particles  gain  the  circulation 
entirely  through  the  veins ;  but  in  carcinoma,  while  the 
cancer  emboli  also  enter  the  blood-stream  by  the  veins, 
the  most  usual  channel  is  the  right  lymphatic  or  the  tho- 
racic duct,  according  to  the  situation  of  the  primary  focus 
of  disease.  In  this  event,  of  course,  the  migratory  elements 
are  discharged  into  the  innominate  veins,  carried  thence 
into  the  pulmonary  vessels,  become  filtered  from  the  blood 
by  the  capillaries  of  the  lungs,  and,  after  their  arrest,  find  in 
this  vascular  tissue  an  excellent  soil  in  which  to  grow. 

In  discussing  secondary  deposits  in  the  lungs  due  to 
cancer-emboli,  it  must  not  be  forgotten  that  cancer  of  adja- 
cent organs,  such  as  the  mammary  glands,  the  oesophagus, 
stomach,  etc.,  may    locally   invade    the    pleura  (permeation), 


DISSEMINATION 


267 


and  give  rise  to  a  widely  scattered  crop  of  miliary  nodules 
on  the  pulmonary  pleura.  This  mode  of  infection  must  be 
distinguished  from  that  in  which  the  lungs  are  infected  by 
emboli  transported  by  the  blood. 

Much  new  light  has  been  thrown  on  the  way  in  which 
cancer  implicates  the  chest- wall  and  infects  the  thoracic  as 
well  as  the  abdominal  organs,  by  the  researches  of  Handley, 


"5S^^^^^-"' 


'-  f 


Fig.  154. — Canceroas  embolus  iu  a  pulmonaiy  capillary  embedded  in  a  thrombus. 

{After  Schmidt.) 

who  has  especially  studied  the  manner  in  which  cancer-cells 
slowly  creep  along  the  planes  of  fascia. 

There  are  many  points  connected  with  the  dissemination 
or  generalization  of  cancer  which  are  not  clearly  explained. 
As  we  shall  find  later  on,  there  are  two  views  as  to  the 
manner  in  which  secondary  cancer  forms  in  bone,  namely, 
the  embolic  theory  and  the  permeation  theory  (Handley). 
Cancerous  cells  enter  the  blood-stream  by  implicating  veins, 
or  by  the  lymphatics.  M.  B.  Schmidt  has  shown  that  these 
cells  excite  thrombosis,  and  the  thrombus  or  clot  contracts 
upon  and  may  ultimately  destroy  them  (Figs.  154  and  155). 


268 


EPITHELIAL    TUMOURS 


This  defending  or  prophylactic  power  of  the  blood  prevents 
colonization  of  the  blood-stream. 

In  regard  to  secondary  cancer  of  vascular  organs,  sucb 
as  the  liver,  bones,  and  ovaries,  reference  may  again  be  made 
to  its  massiveness  as  compared  with  the  size  of  the  primary 
focus  ;  in  these  circumstances,  indeed,  the  continual  progress 
of  the  disease  may  be  described  as  "  ceaseless  cell-proliferation." 

These  large  secondary  formations  are  instructive  from 
another  point  of  view :  primary  cancer  always  arises  on  a 
surface    to    which  air    or   intestinal    gases  have  access,  and 


Fig.  155.- — Pulmonary  capillary  in  section,  showing  cancer  emboli  in  its  lumen. 

{After  Schmidt.) 

therefore  pathogenic  micro-organisms.  The  result  is  ulcera- 
tion, sepsis,  and  destruction  of  the  growth,  followed  by 
septic  infection  and  its  deleterious  consequences. 

Secondary  deposits  in  the  liver,  ovaries,  and  bones  are 
not  so  exposed  in  their  early  stages  to  local  infection,  and 
thus  grow  undisturbed  until  they  attain  proportions  suffi- 
cient to  cause  ulceration  of  the  skin,  or  involve  the  bowel 
and  become  infected ;    then  death   quickly  follows. 

As  a  matter  of  fact,  cancer  is  a  very  chronic  disease, 
save  for  accidental  infections,  and,  as  in  such  chronic  diseases 
as  tabes  and  the  various  sclerotic  changes  of  nerves,  blood- 
vessels, kidneys,  and  liver,  death  really  ensues  from  a  group 
of  diseases  known  as  terminal  infections,  such  as  uraemia, 
pneumonia,  peritonitis,  meningitis,  and  the  like,  due  to  the 
activity  of  many  sjsecies  of  pathogenic  micro-organisms. 


PERMEATION  269 

Secondary  deposits  of  cancer  in  bone.  —  The  distribution 
of  metastatic  cancer  in  bone  has  been  made  the  subject  of 
careful  observation  by  Recklinghausen,  Theile,  Cone,  and 
others.  In  the  preceding  section  some  reference  was  made 
to  this  phenomenon.  The  chief  sources  of  cancer  deposits 
in  bone  are  primary  cancer  of  the  prostate,  thyroid, 
and  mammary  glands :  they  also  occur  in  connexion  with 
primary  cancer  of  the  stomach,  oesophagus,  uterus,  and 
rectum. 

Prostatic  cancer  shows  an  especial  tendency  to  disseminate 
in  bone,  and  Recklinghausen  points  out  that  the  cancer-cells 
lodge  in  the  vascular  channels  of  the  marrow  and  form  a  de- 
posit; as  this  grows,  outrunners  make  their  way  through  the 
adjacent  foramina  of  the  bone  and  form  subperiosteal  deposits. 
A  careful  examination  of  the  distribution  of  secondary  cancer- 
ous deposits  in  bone  bears  this  out,  for  they  occur  in  greatest 
number  where  the  foramina  of  bones  are  largest  and  most 
numerous,  and  a  critical  inspection  of  bones  invaded  by 
secondary  cancer  also  shows  that  in  many  bones  osseous  tissue 
exists  between  the  medullary  cavity  and  the  periosteum,  so 
that  the  growth  has  not  simply  made  its  way  through  by 
erosion. 

The  effect  of  secondary  deposits  growing  in  bone  is  ot 
three  kinds : — 

When  growing  slowly  it  may  simply  erode  the  osseous 
tissue,  or  may  cause  great  expansion  of  the  bone  accompanied 
by  osteoplastic  changes  ;  or  there  is  marked  infiltration  of 
the  bone  without  expansion,  but  with  osteoplastic  changes. 

It  has  been  suggested  that  the  osteoplastic  changes  are 
due  to  chronic  venous  congestion  on  account  of  the  multipli- 
cation of  cancerous  cells  acting  as  a  thrombus. 

These  observations  seem  to  show  that  subperiosteal  can- 
cerous deposits  are  due  to  extension  of  intramedullary 
deposits  through  the  foramina  to  the  subperiosteal  tissues,  and 
are  not  primarily  subperiosteal.  The  matter,  however,  admits 
of  another  interpretation.  Handley  has  made  a  very  careful 
investigation  of  the  mode  in  which  cancer  of  the  mamma  dis- 
seminates, and  shows  that  it  spreads  in  the  thoracic  wall 
by  permeation,  a  slow,  progressive,  centrifugal  serpiginous 
process,  which  is  an  actual  growth  of  the  cancer  along  one  or 


270  EPITHELIAL   TUMOUHS 

other  lines  of  the  parietal  layers  in  continuity  with  the 
primary  groAvth.  He  has  carefully  analysed  the  situation  of 
secondary  deposits  in  this  disease,  and  points  out  that  they 
appear  in  the  near  neighbourhood  of  the  primary  focus, 
and  as  the  disease  advances  the  nodules  occur  at  greater 
distances  from  the  primary  focus  until  at  last,  if  death  is 
unduly  delayed,  they  appear  in  the  trunk  ends  of  the  limbs. 
Hence  the  distal  halves  of  the  limbs  enjoy  an  almost  invari- 
able immunity  from  the  cancerous  nodules.  This  applies  to 
the  bones  of  the  limbs  as  well  as  to  the  skin.  He  believes 
these  facts  to  indicate  that  the  superficial  spread  of  cancer 
takes  place  by  permeation  of  the  deep  fascia.  Moreover,  he 
has  carefully  studied  and  traced  this  infiltration  of  the  deep 
fascia  microscopically. 

Handley  believes  that  visceral  deposits  of  mammary  can- 
cer do  not  arise  from  cells  conveyed  by  the  blood :  according 
to  his  researches  they  occur  through  the  fine  anastomotic 
lymphatics  w^hich  pierce  the  parietes  and  infect  the  subserous 
lymphatics  of  the  pleura  and  peritoneum.  Cancer- cells  then 
escape  into  the  thoracic  and  abdominal  cavities,  implant 
themselves  on  the  surface  of  the  viscera,  and  there  give 
rise  to  deposits  which  terminate  the  life  of  the  patient 
{see  Chap.  li.). 

Cancer-infection. — It  has  long  been  known  that  normal 
cutaneous  epithelium,  when  accidentally  engrafted  into  sub- 
cutaneous tissue,  the  cornea,  or  the  iris,  will  live  and  grow. 
It  has  also  been  demonstrated  beyond  all  cavil  that  when 
women  have  been  ovariotomized,  especially  in  cases  of  large 
ovarian  adenomas,  tumours  have  in  some  instances  grown 
in  the  abdominal  cicatrix;  these  on  microscopic  examina- 
tion have  displayed  cysts  furnished  with  the  regular  large 
mucin-bearing  cells  so  characteristic  of  some  varieties  of 
ovarian  tumours.  As  these  tumours  in  the  cicatrix  have  been 
unassociated  with  any  recurrence  in  the  pelvis,  or  with 
secondary  nodules  in  the  peritoneum  or  in  the  viscera,  the 
conclusion  is  irresistible  that  they  were  due  to  infection  of 
the  edges  of  the  abdominal  incision  in  the  course  of  the 
ovariotomj^  These  cases  are  profoundly  interesting,  be- 
cause they  illustrate  what  often  happens  in  the  course  of 
an  operation   for  the  removal   of  a   cancer;    and   it  is  this 


GANGEB-INFEGTION  271 

local  soiling  of  the  wound  with  minute  cancerous  particles 
that  constitutes  the  accident  which  I  have  called  cancer- 
infection. 

A  careful  study  of  the  clinical  aspects  of  cancer,  as  well  as 
the  most  critical  inquiry  in  the  post-mortem  room,  has 
convinced  many  that  cancer  exhibits  peculiarities  in  regard  to 
mode  of  growth,  infection  of  lymph-glands,  dissemination,  and 
the  way  it  destroys  life,  according  to  the  gland  in  which  it 
arises.  Even  this  only  partly  expresses  the  real  truth,  for  not 
only  is  the  course  of  carcinoma  of  the  same  gland  widely 
modified  by  age  and  constitution,  but  the  same  disease  in 
two  patients,  apparently  alike  in  age  and  environment,  will 
progress  so  differently  that  no  surgeon  can  predict  with  any 
reasonable  certainty  the  expectancy  of  life,  result  of  operation, 
liability  to  dissemination,  or  the  chances  of  recurrence. 
Therefore,  in  deciding  whether  it  will  be  to  the  patient's 
advantage  to  have  a  cancerous  organ  extirpated,  the  surgeon 
is  guided  by  the  known  peculiarities  of  the  particular  organ 
affected,  the  extent  to  which  the  adjacent  tissues  are  impli- 
cated, the  degree  to  which  the  associated  lymph-glands  are 
infected,  and  the  absence  of  signs  indicating  dissemination. 
In  spite  of  every  care,  the  o]3eration  is  occasionally  followed 
by  such  rapid  local  recurrence  that  the  course  of  the  disease 
is  accelerated  rather  than  retarded. 

It  is  a  fact  which  every  surgeon  who  has  had  much 
experience  in  operating  for  cancer  must  have  noticed,  that,  in 
some  instances  where  he  has  conducted  carefully  planned  but 
extensive  operations  for  cancer,  the  patient  has  had  rapid 
recurrence,  and  the  disease  has  manifested  itself  in  a  manner 
far  worse  than  when  left  to  run  its  natural  course.  This 
phenomenon,  I  believe,  may  be  explained.  In  removing  the 
affected  organ  the  infected  lymphatics  and  blood-vessels 
stuffed  with  the  cancerous  material  are  divided,  and  the 
cancer-cells  are  let  loose  over  the  damaged  tissues,  wdiich  they 
infect,  and  lead  to  an  extensive  outbreak  of  local  cancer. 
Knowledge  of  this  kind  is  important,  because  it  leads  us  to 
exercise  greater  care  in  keeping  well  wide  of  the  diseased  area 
whilst  removing  it;  and  though  we  cut  out  the  cancer  with 
its  implicated  lymphatic  ducts  and  infected  lymph-nodes, 
we  should  exercise  every  precaution  not  to  incise  the  diseased 


272  EPITHELIAL   TUMOURS 

parts  and  thus  unwittingly  scatter  the  diseased  cells  over  the 
denuded  surfaces. 

I  have  more  than  once  seen  patients  who  had  been  sub- 
mitted to  operation  for  mammary  cancer,  and  in  whom  the 
removal  had  been  imperfectly  carried  out,  present  on  both 
sides  of  the  scar  a  series  of  cancer  nodules  at  each  stitch- 
hole,  due  to  infection  by  the  needle  and  thread  in  the  course 
of  the  operation.  The  most  striking  example  of  cancer- 
infection  under  my  own  observation  occurred  in  a  woman 
aged  58  years.  I  excised  a  cancer  from  her  descending  colon. 
Nine  months  later  a  tumour  as  big  as  a  bantam's  egg  was 
removed  from  the  scar  left  by  the  incision  in  the  belly-wall : 
this  tumour  exhibited  microscopic  features  identical  with 
those  of  the  primary  tumour  in  the  bowel.  In  the  course 
of  the  operation  I  carefully  inspected  the  interior  of  the 
abdomen  and  found  the  omentum  and  bowels  free  from  all 
visible  signs  of  dissemination.  It  is  obvious  that  the  edges 
of  the  abdominal  incision  were  infected  with  cancer  during 
the  removal  of  the  primary  tumour. 

Transference  of  cancer  by  contact. — Many  cases  have 
been  reported  which  are  supposed  to  prove  that  cancer  may 
be  transplanted  by  the  direct  contact  of  a  cancerous  surface 
either  with  another  part  of  the  infected  person's  body  or  with 
another  person.  The  examples  of  the  first  condition  usually 
mentioned  are  the  infection  of  the  skin  of  the  arm  from  contact 
with  an  ulcerating  carcinoma  of  the  breast,  and  the  infection 
of  a  labium  by  a  squamous-celled  cancer  in  the  opposite 
labium.  I  have  never  seen  the  upper  lip  infected  from 
contact  with  a  cancerous  lower  lip,  nor  the  cheek  infected 
save  by  extension  of  the  growth  in  the  case  of  cancer  of  the 
tongue.  It  is  also  a  matter  of  common  observation  that  even 
in  extensive  cancer  of  the  tongue,  jaws,  or  pharynx,  quantities 
of  cancerous  particles  find  tbeir  way  into  the  stomach,  but 
the  mucous  membrane  of  the  gastro-intestinal  tract  escapes. 
Surgeons  who  are  actively  engaged  almost  daily  in  performing 
operations  for  cancer  frequently  cut  or  prick  their  fingers,  but 
a  cancer  transplanted  in  this  way  is  unknown ;  in  contrast  to 
this,  it  may  be  mentioned  that  there  is  probably  no  surgeon 
who  has  not  infected  himself  in  this  way  with  some  form  of 
septic  disease. 


EEBDDITY  273 

This  should  make  us  careful  in  accepting  evidence  in 
regard  to  what  is  sometimes  called  cancer-d-deux,  in  which  a 
cancerous  ulcer  appears  on  the  penis  of  a  man  cohabiting 
with  a  woman  suffering  from  cancer  of  the  neck  of  the 
uterus,  or  vice  versa. 

Heredity. — This  is  another  difficult  problem,  or  it  would 
be  better  termed  a  vexed  question,  in  regard  to  cancer  and 
malignant  disease  generally,  because  so  much  that  appears 
to  be  affirmative  is  founded  on  false  facts — that  is,  on  cir- 
cumstances that  cannot  be  tested  or  proved.  The  statement 
that  the  father  died  of  cancer  of  the  prostate,  and  the 
mother  of  a  sarcoma  of  the  humerus,  is  scarcely  a  good 
explanation  of  the  cause  of  a  malignant  dermoid  or  em- 
bryoma  in  their  infant  daughter.  When  several  female 
members  of  a  family  die  from  cancer  of  the  breast,  it  will 
be  found,  on  careful  inquiry,  that  they  have  lived  in  the 
sauie  environment.  The  question  of  cancerous  inheritance 
bristles  with  difficulties,  many  of  which  are  at  present 
insuperable. 

Bayha,  H.,  "  Ueber  Lupuscarcinom."— -Sei^.  z.  Idin.  Chir.,  1888,  iii.  1. 

Berry,  James,  "  Carcinoma  following  Lupus  of  Face." — Trans.  Path.  Soc, 
1891,  xlii.  308. 

Bowlby,  Anthony  A.,  "A  Case  of  Epithelioma  of  the  Ear."— lV««s.  Path.  Soc, 
1884,  XXXV.  330. 

Brand,  "  The  Etiology  of  Cancer."— 2?ri/.  Med.  Journ.,  1902,  ii.  238. 

Cone,  "  A  Case  of  Carcinoma  Metastasis  in  Bone  from  a  Primary  Tumour  of 
the  Prostate." — Bull.  Johns  Hopldns  Hos^p.,  1898,  xv.  114. 

Foulerton,  "A  Case  of  Squamous- celled  Carcinoma  of  the  Finger,  associated 
with  frequent  and  prolonged  exposure  to  X-rays." — Trans.  Path.  Soc, 
Iviii.  327. 

Handley,  W.  Sampson,  "  The  Centrifugal  Spread  of  Mammary  Carcinoma  in 
the  Parietes."— J.w7t.  of  Middx.  Hosp.,  1904,  iii.  27. 

Hillier,  W.  T.,  "Carcinoma  of  the  Thoracic  Duct." — Tra7is.  Path.  Soc,  1903, 
liv.  153. 

Hillier,    W.   T.,    "Some  Remarks  on  Cancer  of  the  Liver  and  Panci-eas. " — 

Arch,  of  Middx.  Hosp.,  1903,  i.  123. 
Hulke,  J.  W.,  "  Epithelioma  of  the  Side  of  the  Head  perforating  the  Skull." — • 

Trans.  Path.  Soc,  1875,  xxvi.  187. 

Langhans,  D.  G.,  "  Primarer  Krebs  der  Trachea  und  Bronchien." — Yirchow's 
Arch.f.  path.  Anat.,  liii.  470. 
je,  T.  M.,  "  Pitch  Cancer." — Brit.  Med.  Journ.,  1910,  ii.  1370. 

S 


274  EPITHELIAL   TUMOURS 

Marshall,  C.  L.  Devereux,  "Metastatic  Carcinoma  of  the  Ej'eball." — Hoy. 
Lond.  Opltthal.  Hosp.  Bepts.,  1897,  xiv.  415. 

Mathieu,  Albert,  et  Hattan-Lorrier,  L.,  "  Cancer  du  Canal  Tlioracique,  con- 
secutif  a  un  Cancer  de  I'Estomac." — Bull,  et  Mem.  de  la  Soc.  Med.,  Paris, 
1898,  XV.  827. 

Neve,  E.  F.,  "  One  Cause  of  Cancer  as  illustrated  by  Epithelioma  in  Kashmir." — 
Brit.  Med.  Jowrn.,  1910,  ii.  589. 

Passler,  Hans,  "  Ueber  das  Primare  Carcinom  der  Lunge." — Virchow's  Arcli.f. 
j,ath.  Anat.,  cxiv.  191. 

Pryce-Jones,  C,  "  The  Cytology  of  the  Blood  in  Malignant  Disease,  with 
Literature." — Hepts.  from  the  Cancer  Besearch  Laboratories  of  Middx. 
Hasp.,  1902,  i.  113. 

Rowan,  J.,  "  Metastatic  Carcinoma  of  the  Choroid  from  a  Primary  Carcinoma 
of  the  h\mg."— Trans.  OpUlial.  Soc.  of  U.K.,  1899,  xix.  103. 

Rowntree,  C.  W.,  "  Contribution  to  the  Study  of  X-Ray  Carcinoma  and  the 
Conditions  which  precede  its  Onset." — Arch,  of  Middx.  Hosp.,  1908,  xiii. 
182. 

Theile,  "  On  Secondary  Carcinomatosis  of  Bones  and  Osteoplastic  Changes 
connected  with  them." — Trans.  Path.  Soc,  Iviii.  814. 

Troisier,  "  Le  Cancer  du  Canal  Thoracique." — B^ill.  et  Mem.  de  la  Soc.  Med., 
Paris,  1898,  xv.  455. 

Unger,  E.,  "Krebs  des  Ductus  thoracicus."— Virchow's  ^rc/j./.  ^;a^7i.  Anat.,. 
1896,  cxlv.  581. 

Williams,  W.  Roger,  "  Epithelioma  of  the  External  Ear." — Trans.  Path.  Soc, 
1884,  XXXV.  331. 


CHAPTER  XXVI 
CONCERNING  THE  CAUSE  OF  CANCER 

The  cause  (pathogenesis)  of  carcinoma  has  for  many  years 
been  a  fascinating  subject  of  inquiry  and  has  led  to  much 
speculation,  some  of  which  has  had  great  influence  in  directing 
research  along  particular  lines.  Great  obscurity  surrounds 
the  cause  of  this  disease,  because  our  knowledge  depends  on 
observation  alone;  all  attempts  to  elucidate  the  problem  by 
experiment  have  been  complete  failures,  therefore  observation 
has  been  supplemented  by  theory.  Among  the  hypotheses  or 
guesses  at  truth  in  connexion  with  this  matter  there  are  three 
which  require  consideration : — 

1.  The  Embryonic. 

2.  The  Parasitic. 

3.  The  Biologic. 

1.  The  embryonic  theory.  —  Cohnheim  attempted  to 
ascribe  the  origin  of  malignant  tumours  to  cells,  or  groups  of 
cells,  which  are  not  utilized  in  the  development  of  the  body  in 
its  early  or  embryonic  stages,  and  he  assumed  that  these 
residues  or  "  rests "  retain  potential  powers  of  growth,  and 
later  in  life  they  suddenly  and  without  obvious  provocation 
assume  active  growth  and  become  tumours. 

This  theory,  unsupported  by  any  concrete  evidence,  was 
advanced  by  Cohnheim  as  an  explanation  of  the  origin  of 
connective-tissue  and  epithelial  tumours.  The  great  argu- 
ment against  it  was  to  the  effect  that  unutilized  embry- 
onic tissue  or  rests  had  not  been  demonstrated ;  but  it 
suggested  a  line  of  inquiry  in  which  observation  proved  the 
existence  of  tissue-islets  which  in  some  instances  could  be 
regarded  as  potential  sources  of  tumours  belonging  to  the 
so-called    innocent   group.      Experimental    inquiry   did   not 

275 


^7«  EPITHELIAL   TUMOURS 

support  the  theory,  and  as  an  explanation  of  the  origm  of 
malignant  tumours  it  has  signally  failed. 

The  term  rests,  used  in  discussmg  the  pathogenesis  of 
tumours,  should  be  reserved  for  detached  fragments  of  secret- 
ing glands  and  isolated  portions  of  epithelium.  Examples  of 
this  kind  occur  in  connexion  with  the  spleen  (splenculi) ;  an 
accessary  pancreas  is  well  known,  and  it  may  be  lodged  in  the 
wall  of  the  duodenum  or  jejunum.  Accessary  thyroid  glands 
and  adrenals  are  by  no  means  uncommon,  and  reference  is 
made  to  them  in  appropriate  places  in  this  book. 

In  addition  to  rests  being  represented  by  detached  portions 
of  an  organ,  it  has  been  shown  that  they  ma}^  occur  as  isolated 
portions  of  gland- tissue  within  the  organ  itself.  Gland-islets 
of  this  kind  have  been  observed  in  the  liver  and  in  the 
mamma;  it  is  possible  that  such  sequestered  portions  of 
glandular  tissue  may  be  the  source  of  encapsuled  adenomas. 
Rests  composed  of  epithelium  have  been  detected  in  the  line 
of  the  mesopalatine  suture,  and  on  the  gums  {see  p.  231) ;  but 
in  the  non-epithelial  tissues  they  do  not  admit  of  ready  recog- 
nition. The  best  examples  are  the  islets  of  cartilage  in  the 
vicinity  of  the  epiphysial  lines  of  long  bones  in  rickety 
children  (p.  26).  Such  belated  pieces  of  cartilage  maj^  be  the 
source  of  a  chondroma. 

Efibrts  have  been  made  to  extend  Cohnheim's  theory  in 
regard  to  rests  as  an  explanation  of  the  origin  of  malignant 
tumours  by  supposing  that  islets  of  glandular  tissue  may  be 
formed  in  organs  as  a  result  of  inflammatory  changes,  such 
isolated  tissues  being  supposed  to  acquire  proliferative  power 
and  become  tumours.  In  order  to  distinguish  belated  tracts 
arising  in  this  way  from  the  embryonic  residues,  it  has  been 
proposed  to  term  them  "  post-natal  rests."  This  extension  of 
the  embryonic  hypothesis  has  not  met  with  success. 

Care  must  be  taken  not  to  confound  rests  with  vestiges. 
The  term  vestige  should  be  reserved  for  those  organs  which 
are  of  importance  to  the  embryo  and  foetus,  but  useless 
to  the  adult,  such  as  the  vitello-intestinal  duct,  the  round 
ligament  of  the  liver,  the  mesonejihros,  etc. ;  also  the  repre- 
sentatives of  those  organs  which,  though  utilized  in  the 
male,  are  useless  in  the  female,  and  vice  versa,  such  as  Gartner's 
duct,  the  parovarium,  etc.     There  are  structures  which,  so  far 


CAUSE  OF  CAXCER  277 

as  we  know,  serve  no  useful  purpose  in  any  vertebrate  at 
present  living,  but  were  doubtless  of  importance  to  their 
ancestors.  Examples  of  this  are  the  central  canal  of  the 
spinal  cord,  the  cerebral  ventricles,  pineal  eye,  etc. 

Cohnheim's  theory  has  commanded  much  attention:  it 
is  in  itself  a  brilliant  generalization,  and  has  served  a  valu- 
able purpose  in  leading  to  a  great  extension  of  knowledge 
concernincj  vestiges  and  rests. 

In  regard  to  congenital  defects  of  tissues  as  the  subsequent 
sources  of  malignant  tumours,  the  most  obvious  are  those 
known  as  birth-marks  or  moles.  Many  hundreds  of  these 
blemishes  come  under  the  notice  of  trained  observers  yearly, 
but  probably  not  one  black  mole  in  a  thousand  becomes  the 
source  of  a  melanoma,  or  an  endothelioma. 

Trauma  in  relation  to  malignant  tumours. — Injury  as 
an  etiological  factor  has  only  been  seriously  advanced  in 
the  case  of  the  breast  and  the  testicle,  two  organs  particu- 
larly exposed  to  injury. 

The  majority  of  women  receive  in  the  course  of  their 
lives  an  accidental  blow  upon  their  breasts,  and  the 
frequency  with  which  women  attribute  the  cause  of  a 
cancerous  tmnour  within  the  breast  to  an  injury  is  largely 
due  to  the  belief,  deeply  rooted  in  their  minds,  that  such 
injuries  are  the  common  cause  of  cancer.  About  10  per 
cent,  of  patients  with  this  disease  in  their  breast  can,  and 
do,  assign  a  specific  injury  as  the  starting-point. 

Sarcomas  are  unusual  tumours  of  the  breast  and  form 
about  10  per  cent,  of  the  malignant  tumours  of  this  organ. 
Of  some  recent  statistics  the  following  may  be  mentioned  : 
Among  335  tumours  of  the  breast,  33  were  sarcomas  (Poulsen 
of  Copenhagen).  In  Bergmann's  clinic  there  were  34  sar- 
comas among  359  mammary  tumours.  Schmidt  found  in 
139  cases  of  malignant  disease  of  the  breast  126  examples 
of  carcinoma  and  13  of  sarcoma.  Homer  amoncr  172 
malignant  tumours  of  the  breast  found  14  sarcomas.  Sar- 
coma occurs  at  an  earher  age  than  cancer,  and  women  are 
most  liable  to  this  form  of  malignant  disease  between  the 
twentieth  and  fortieth  years  of  life,  whereas  cancer  is 
most  frequent  between  the  thirty-fifth  and  fiftieth  years. 
As   with  cancer,    patients    often    attribute    the    tumour    to 


278  EPITHELIAL   TUMOURS 

an  injury,  especially  to  what  may  be  called  an  "  intensive 
injury." 

It  is  a  fact  that  surgeons  see  many  patients  with  sarcoma 
and  carcinoma  who  cannot  recall  any  injury  to  the  part : 
and  of  the  enormous  number  of  contusions  and  injuries  only 
an  infinitesimal  proportion  is  followed  by  a  malignant  tumour. 
Small  as  is  this  number,  the  circumstances  relating  to  these 
sequences  are  such  as  to  lead  surgeons  to  believe  that  a  single 
"  intensive "  injury  may  occasionally  induce  the  growth 
of  a  sarcomatous  tu'niour,  and  place  it  outside  the  category 
of  mere  coincidence. 

The  attitude  of  surgeons,  as  reflected  in  their  writings, 
towards  trauma,  or  physical  insults,  as  an  etiological  factor 
in  the  production  of  malignant  tumours  in  the  breast,  justifies 
the  following  statement : — 

In  regard  to  cancer  (carcinoma),  all  surgeons  of  experience 
admit  that  there  is  a  definite  history  of  intensive  mechanical 
injur}/^  in  about  10  per  cent,  of  the  patients.  They  are  very 
careful  not  to  express  a  definite  opinion  as  to  the  causal 
relationship  of  such  injuries  to  the  formation  of,  cancer  in 
the  breast.  There  is  also  a  paucity  of  published  statements 
from  surgeons  of  great  experience  affirming  trauma  as  a 
cause  of  mammary  cancer. 

In  regard  to  sarcoma  of  the  breast,  there  is  a  definite 
opinion  held  by  experienced  surgeons  to  the  effect  that 
there  are  many  carefully  observed  and  thoroughly  reported 
cases  in  which  primary  sarcoma  of  the  breast  has  quickly 
supervened  on  a  single  intensive  injury.  The  sarcomatous 
nature  of  such  tumours  has  been  ascertained  by  a  microscopic 
examination  at  the  hands  of  a  competent  pathologist,  and 
their  malignant  nature  has  been  confirmed  by  the  early 
death  of  the  individual.  It  is  undeniable  that  a  single  in- 
tensive blow  or  knock  on  the  breast  may  be  occasionally 
followed  by  a  sarcomatous  tumour. 

2.  The  parasitic  theory.  —  Many  who  are  thoroughly 
acquainted  with  the  clinical  and  pathological  features  of 
carcinoma  feel  strongly  that  this  disease  will  ultimately  come 
to  be  defined  as  a  chronic  infective  disease  due  to  a  micro- 
parasite  luhich  selects  an  epithelial  cell. 

The  brilliant  results  of  microscopic  inquiry  during  the  last 


CAUSE  OF  GANGER  279 

thirty  years  into  the  causes  of  disease  have  added  to  the 
number  of  parasitic  diseases  previously  known  to  us. 

It  has  become  customary,  in  describing  the  vegetable  and 
animal  parasites  infesting  man,  to  speak  of  the  flora  and 
fauna  of  the  human  body.  This  application  of  a  natural- 
history  expression  is  useful,  perhaps  even  picturesque,  and 
it  is  certainly  an  improvement  on  many  of  the  dry  and 
commonplace  terms  used  in  medical  writings ;  moreover,  the 
expression  is  true. 

As  the  living  things  in  a  brook  thrive  best  in  certain  haunts, 
so  the  vegetable  and  animal  forms  which  infest  animal  bodies 
exhibit  a  marked  preference  tor  certain  organs  and  tissues  in 
which  to  live  and  grow.  For  example,  the  demodex  prefers  the 
hair-follicles,  whilst  ankylostomum  selects  the  mucous  mem- 
brane of  the  duodenum  ;  the  malaria  parasite  finds  its  way  into 
an  erythrocyte ;  filarise  swim  freely  in  the  liquor  sanguinis ; 
CoccidiuTYi  ovifornie  finds  its  way  into  the  epithelium  of  the 
biliary  passages  ;  and  the  embryo  of  Tcenia  echinococciis  prefers 
subserous  areolar  tissue,  whilst  the  adult  form  of  this  tape- 
worm chooses  the  mucous  membrane  of  the  dog's  duodenum. 

Among  infectious  diseases,  the  most  extraordinary  and 
some  of  the  deadliest  are  those  in  which  the  infecting  agent 
gains  access  to  the  body  by  inoculation,  that  is,  through 
abrasions,  cuts,  or  punctures  of  the  skin  or  mucous  membrane. 
Familiar  examples  of  this  are  tetanus,  hydrophobia,  leprosy, 
glanders,  actinomycosis,  and  syphilis.  The  point  of  inoculation 
is  known  as  the  primary  focus  of  the  disease,  and  at  this 
source  the  parasites  multiply,  enter  the  circulation  and  lymph- 
stream,  whence  they  may  be  distributed  throughout  the  body, 
often  to  form  secondary  foci  of  disease  which  interfere  with 
the  functions  of  the  organs  in  which  they  may  chance  to 
grow,  as  well  as  with  the  nutrition  of  the  body  by  means  of 
the  toxins  they  brew  and  discharge  into  the  blood,  producing 
a  form  of  slow  poisoning. 

The  facts  which  support  the  parasitic  theory  of  cancer  may 
be  summarized  in  the  following  way :  In  its  initial  stages  the 
disease  is  purely  local,  then  gradually  it  spreads  to  the  adjacent 
tissues,  and  at  the  same  time  infects  the  lymph-glands  which 
receive  the  lymphatics  from  the  affected  area,  and  general 
infection  of  the  body  (dissemination)  follows. 


230  EPITHELIAL    TUMOURS 

Some  writers  refer  to  the  toxic  effects  (cacliexia)  exhibited 
by  individuals  with  well-established  cancer  as  evidence  in 
favour  of  its  parasitic  origin;  but  Cooper  believes  that  this 
toxic  effect  has  been  exaggerated,  and  points  out  that  it  is 
absent  even  in  extensive  cancer  where  no  ulceration  or 
external  contamination  is  present.  When  micro-organisms 
gain  access  they  find  a  malignant  growth  a  favourable  nidus 
for  their  development,  and  septic  intoxication  more  or  less 
rapidly  ensues.  This  matter  was  discussed  in  the  preced- 
ing chapter  in  relation  to  the  manner  in  which  death  so 
often  occurs  in  the  cancerous  by  what  are  called  terminal 
infections  {see  p.  268). 

In  many  instances  cancer  seems  to  have  a  period  of 
quiescence,  and  then  to  enter  on  a  period  of  recrudescence, 
exactly  like  a  chronic  infectious  disease  such  as  syphilis.  The 
primary  focus  in  this  disease  disappears  after  a  time  and 
leaves  but  little  trace  of  its  existence,  so  occasionally  in 
carcinoma  the  primary  focus  may  atrophy  and  become 
inconspicuous.  The  infectiveness  and  vitality  of  the  cancer-cell 
have  been  already  discussed,  and  form  a  strong  argument  for 
those  who  are  seeking  for  a  parasite ;  but  to  my  mind  the 
most  valuable  evidence  is  supplied  by  the  distribution  of 
the  initial  lesions  of  cancer. 

When  cancer  arises  on  those  parts  of  the  body  easily 
accessible  to  observation,  such  as  the  lips  and  tongue,  it  is 
always  preceded  by  a  wound,  chronic  inflammation,  and  especi- 
ally chronic  syphilitic  lesions.  It  is  also  recognized  that  the 
disease  occurs  most  frequently  in  situations  where  there  is 
access  of  air,  and  on  free  surfaces,  as  in  the  case  of  the  intes- 
tinal tract ;  and  it  is  clearly  established  by  a  careful  study  of 
death-returns  that  in  more  than  half  the  cases  in  which  death 
is  attributed  to  cancer  the  primary  seat  of  the  disease  is  in  the 
digestive  organs.  The  distribution  of  cancer  in  that  part  of 
the  alimentary  canal  which  occupies  the  belly  is  somewhat 
remarkable.  For  example,  the  stomach  is  not  only  the  com- 
monest primary  seat  of  cancer  when  compared  with  other 
digestive  organs,  but  it  stands  third  in  order  of  frequency 
among  all  organs,  the  breast  (mamma)  being  first  and  the 
uterus  second  in  order  of  liability.  The  small  intestine  (duo- 
denum, jejunum,  and  ileum)  is  very  rarely  attacked- by  cancer. 


CAUSE   OF  GANGER  281 

but  in  the  rest  of  the  canal  (colon  and  rectum)  it  is  a  very 
frequent  disease.  These  facts  give  colour  to  the  hypothesis 
that  the  cause  of  cancer  is  a  micro-parasite  conveyed  by 
uncooked  food  or  water. 

When  men  and  women  are  impatient  at  our  ignorance  in 
regard  to  the  cause  of  cancer,  it  is  well  to  remind  them  that 
the  part  played  by  the  spermatozoon  in  fertilizing  the  ovum 
has  only  been  known  about  sixty  years.  Need  we  complain 
that  it  has  been  so  difficult  to  find  the  cause  of  cancer  ?  It  is 
most  probably  a  micro-parasite  which  stimulates  the  normal 
epithelial  cells  of  adult  individuals  to  multiply  and  produce 
cancer  in  the  same  way  that  the  male  gamete  or  spermato- 
zoon initiates  reproductive  changes  in  the  female  gamete 
or  ovum. 

The  feature  which  distinguishes  carcinoma  from  all  in- 
fective diseases  is  its  property  of  causing  secondary  deposits 
which  reproduce  the  structural  details  of  the  organ  primarily 
affected.  This  remarkable  vitality  of  epithelium  is,  of  course, 
exhibited  in  its  highest  form  by  the  ovum,  which  is  an  epi- 
thelial cell,  and  one  which,  under  certain  conditions,  exhibits 
malignancy  in  a  very  extraordinary  form  (Chap.  XLix.). 

3.  The  biologic  theory  and  the  cytologic  transforma- 
tions observed  in  malignant  tumours. — Among  the  most 
important  observations  which  have  been  recorded  in  relation 
to  cells  of  malignant  tumours,  attention  must  be  given  to 
those  made  by  Farmer,  Moore,  and  Walker  in  relation  to 
nuclear  division. 

It  is  known  that,  in  the  production  of  sexual  (gametogenic) 
cells  in  plants  and  animals,  the  forms  of  nuclear  division 
differ  materially  from  those  exhibited  by  cells  which  compose 
the  tissues  of  the  body  (somatic  cells).  The  above-mentioned 
investigators  have  been  able  to  trace  in  detail  a  number  of 
definite  and  serial  changes  in  the  cells  of  invading  and  pro- 
liferating malignant  tissues  which  are  remarkably  similar  to 
those  obtained  during  the  maturation  of  the  elements 
contained  within  the  sexual  reproductive  glands,  and  this 
resemblance  extends  to  minute  points  of  detail. 

These  observations  show  that  the  various  types  of 
malignant  growths  present  certain  features  in  their  cy to- 
logical  transformations  common  to  all,  and  that  these  features 


282  EPITHELIAL   TUM0UB8 

are  similar  to  those  to  be  observed  in  the  process  of  differentia- 
tion of  reproductive  cells  from  the  preceding  somatic  tissue. 
The  evidence,  the  investigators  believe,  justifies  them  in 
correlating  the  appearance  of  these  "  gametoid "  neoplasms 
with  the  result  of  a  stimulus  which  has  changed  the  normal 
somatic  course  of  cell-development  into  that  characteristic  of 
reproductive  (not  embryonic)  tissue.  These  peculiar  nuclear 
changes  have  not  been  observed  in  innocent  tumours. 

The  same  investigators  have  succeeded  in  showing  that 
the  remarkable  vesicular  structures  found  in  cancer-cells, 
known  as  "  bird's-eye  inclusions  "  or  Plimmer's  bodies,  occur 
normally  in  cells  during  the  production  of  sexual  elements  in 
vertebrates.  These  bird's-eye  inclusions  consist  of  a  well- 
defined  wall  enclosing  a  clear  fluid  in  which  are  suspended 
one  or  more  darkly-staining  granules.  In  size  they  may  be 
very  minute,  or  may  equal  the  nucleus.  One,  or  as  many  as 
twenty,  may  occur  in  the  same  cell ;  they  commonly  lie 
adjacent  to  the  nucleus,  which  they  frequently  press,  giving  it 
a  crescentic  appearance.  These  bodies  are  very  conspicuous, 
and  were  long  regarded  as  peculiar  to  malignant  growths; 
they  acquired  some  notoriety  on  account  of  their  resemblance 
to  Plasmodiophora  hrassicce,  discovered  by  Woronin  in  1876 
as  the  cause  of  a  disease  of  the  edible  Crucifera?,  especially 
cabbages ;  this  relationship,  however,  has  not  passed  beyond 
the  bounds  of  speculation. 

Now  that  Farmer  and  his  co-workers  have  shown  that  the 
archoplasTnio  vesicles,  as  they  have  been  called,  appear  during 
spermatogenesis  in  all  vertebrates,  and  are  to  all  appearance 
structurally  identical  with  and  arise  in  a  manner  similar  to 
the  "  bird's-eye  inclusions"  in  the  cells  of  cancer  (Plimmer's 
bodies),  it  rather  weakens  beUef  in  their  specificity  for 
malignant  growths. 

The  peculiar  nuclear  changes  observed  in  the  cells  of 
malignant  growths  do  not  affect  all  the  cell-elements  equally ; 
those  which  show  the  changes  in  the  highest  degree  are 
"  situated  in  a  zone  behind  the  growing  edge  of  the  advancing 
neoplasm." 

In  the  slow-growing  tumours  which  produce  a  considerable 
amount  of  normal  somatic  tissue  (fibrous  tissue),  cells  showing 
the  phases  here  referred  to  are  far  more  difficult  to  find  than 


CAUSE  OF  GANGER  283 

in  the  rapidly  growing  tumours.  In  such  growths,  cells  show- 
ing the  figures  of  ordinary  somatic  division  are  numerous 
in  comparison  with  those  showing  heterotype  figures.  This 
would  seem  to  indicate  that  the  cells  which  are  destined  to 
form  fibrous  tissue  never  divide  heterotypically. 

These  observers  look  upon  this  remarkable  transformation 
as  representing  the  immediate  cause  of  development  of  the 
malignant  growth,  but  the  remote  cause,  the  specific  irritant, 
has  yet  to  be  found.  Nevertheless,  the  interesting  changes 
which  they  have  detected  constitute  a  valuable  and  inter- 
esting item  in  our  knowledge  of  the  cytology  of  malignant 
tumours. 

Bonney  has  shown  that  a  gametoid  type  of  mitosis  occurs 
in  the  cells  of  intracystic  papilloma  of  the  ovary  and  in 
the  cells  of  the  gonorrhoeal  wart. 

In  describing  the  histologic  features  of  primary  and 
secondar}^  cancerous  tumours,  it  was  pointed  out  that  the 
epithelium  resembled  that  of  the  part  in  which  the  cancer 
arose  primarily,  and  that  in  the  case  of  a  carcinoma  arising 
in  a  glandular  organ  the  cells  not  only  resembled  the  cells  of 
the  gland,  but  the  grouping  of  the  cells,  especially  in  the 
secondary  deposits,  was  a  mimicry,  so  to  speak,  of  the  gland 
itself.  This  peculiarity  of  carcinoma  has  attracted  the  close 
attention  of  all  investigators  who  have  made  the  structure  of 
cancers  a  special  subject  of  study,  and  this  aspect  of  the 
matter  has  seemed  to  become  more  thoroughly  established 
with  each  improvement  and  refinement  in  histologic  methods, 
until  it  seemed  to  be  a  matter  which  did  not  admit  of 
dispute. 

The  subject  has  been  carefully  investigated  by  Cooper, 
who  points  out  in  regard  to  it  that  no  one  has  witnessed  on  the 
stage  of  a  microscope  the  actual  conversion  of  a  normal  into 
a  malignant  cell,  and  reminds  us  that  cells  of  an  embryonic 
type,  and  possessing  considerable  powers  of  reproduction,  are 
normally  present  in  our  tissues  throughout  life,  and  play  an 
important  part  in  what  may  be  called  tissue  maintenance;  and 
he  ventures  on  the  suggestion  that  cancer-cells  are  formed 
from  the  histogenic  cells  of  the  body,  and  are  therefore 
most  probably  of  a  primary  embryonic  origin,  but  that  they 
have  departed  morphologically  and  physiologically  from  the 


284  EPITHELIAL   TUMOURS 

normal  type  of  the  histogenic  cell.  The  cancer-cell  resembles 
its  embryonic  prototype  from  the  fully  formed,  functionally 
active  tissue-cell  of  the  adult  in  the  following  particulars : — 

1.  Its  generalized  shape,  which,  although  variable  and 
irregular,  inclines  on  the  whole  to  be  spherical ;  often, 
however,  the  natural  shape  is  altered  by  pressure.  2.  Its 
comparatively  large  nucleus,  which  often  indicates  evidence 
of  division.  3.  Its  more  or  less  homogeneous  protoplasm  and 
the  large  proportion  of  glycogen.  The  cancer-cell  differs  from 
the  normal  prototype  in  several  points,  such  as  its  simple 
method  of  cell-division ;  powers  of  movement  or  migration ; 
ability  to  engulf  albuminous  particles,  and  its  proneness 
to  undergo  degeneration.  These  observations  support  the 
view  that  cancer-cells  are  intrinsic  to  the  body,  and  that  they 
are  derived  from  the  pre-existing  and  presumably  normal 
cells  of  the  body. 

The  careful  histological  study  of  malignant  tumours 
reveals  in  a  decided  way  that  in  whatever  kind  of  tissue  a 
sarcoma  arises,  its  malignancy  may  be  fairly  gauged  according 
to  the  degree  in  which  it  departs  from  the  normal  towards 
the  round-celled  type  of  tissue ;  in  the  same  way  the  greater  the 
deviation  of  the  epithelial  cells  of  a  cancer  towards  the  spher- 
oidal cell,  and  the  more  it  caricatures  in  the  arrangement  of 
the  cells  the  structure  of  the  gland  in  which  it  arises,  the 
more  dangerous  is  it  likely  to  be  to  the  life  of  the  individual 
in  whom  it  occurs. 

Perversions  in  type  of  this  kind  used  to  be  expressed  by 
the  term  ^metaplasia ;  but  there  is  a  tendency  to  restrict  this 
name  to  express  the  mutation  of  epithelium  from  a  columnar 
cell  to  the  flattened  or  squamous  kind. 

The  deviation  of  the  tumour- tissues  from  the  normal  type 
towards  the  round  cell  in  the  case  of  connective  -  tissue 
tumours,  and  to  the  spheroidal  cell  in  the  case  of  epithelial 
tumours  (carcinoma),  is  now  conveniently  expressed  by  the 
term  ana.pUtsia.,  and  it  is  possible  to  express  this  structural 
alteration  in  the  form  of  a  law :  The  degree  of  ctnaplasia 
exhibited  hy  a  turnour  rejjresents  the  d.egree  of  its  malignancy. 
This  is  a  scholastic  form  for  expressing  a  fact  long  recognized, 
that  the  more  a  tumour  diverges  from  the  type  of  its  matrix 
the  greater  the  malignamcy. 


GAU8E   OF  CANCER  285 

For  many  years  after  Yirchow  taught  that  every  tissue  in 
a  tumour  had  a  physiological  prototype,  it  seemed  difficult  to 
find  a  satisfactory  example  of  the  erosive  power  of  the  cancer- 
cells  ;  but  the  researches  into  the  remarkable  tumour  known 
as  chorion-epithelioma  have  taught  that  the  trophoblast  of 
the  developing  embryo  resembles  in  this  respect  a  mahgnant 
tumour,  except  that  in  health  it  affects  a  limited  area  of 
the  maternal  tissue;  but  when  abnormal  and  excessive  it 
exhibits  malignancy  in  all  its  forms,  recurrence  after  re- 
moval, wide  dissemination  and  invasiveness. 

The  strongest  argument  against  the  parasitic  theory  is  the 
failure  to  cultivate  the  cancer-cell  outside  the  body,  and  in 
this  connexion  reference  may  be  made  to  the  important 
observations  and  experiments  of  Jensen  on  tame  mice.  It 
appears  that  mice  are  liable  to  tumours  which  run  a  malig- 
nant course.  Jensen  has  been  able  to  transplant  portions 
of  the  tumour  into  other  mice  with  success  through  nineteen 
generations.  The  original  tumour  occurred  sporadically  in 
a  white  mouse,  and  although  the  transplantations  were 
successful  with  various  kinds  of  mice  except  those  known 
as  blue  mice,  the  experiments  succeeded  best  with  white  mice. 
Jensen's  experiments  have  been  repeated  in  London  by 
Dr.  Bashford,  and  similar  results  have  been  obtained. 

In  order  to  emphasize  the  difficulty  of  what  for  conveni- 
ence may  be  termed  the  cancer  question,  it  is  necessary  to 
mention  that  competent  pathological  and  bacteriological 
investigators,  who  have  conducted  the  most  painstaking  and 
laborious  researches  with  the  hope  of  discovering  the  cause 
of  carcinoma  and  sarcoma,  are  divided  into  two  camps,  namely, 
those  who  strongly  believe  that  it  is  due  to  a  micro-parasite, 
either  a  bacterium  or  some  lowly  animal  form  such  as  a 
protozoon ;  and  those  who  think  the  disease  is  due  to  some 
altered  conditions  of  the  cells  independent  of  parasites.  The 
position  for  the  non-expert  in  this  matter  is  illustrated  by  the 
following  lines  from  "  Empedocles  on  Etna  "  : — 

"  The  gods  laugh  in  their  sleeve 
To  watch  man  doubt  and  fear, 
Who  knows  not  what  to  believe, 
Since  he  sees  nothing  clear, 
And  dares  stamp  nothing  false  where  he  finds  nothing  sure.' 


286  -    EPITHELIAL   TUMOURS 

AVhilst  investigators  are  hunting  for  tlie  cause  of  ma- 
lignant tumours,  practical  surgeons  have  to  deal  with  the 
concrete  disease. 

Bonney,  V.,  "  On  Gametoid  Types   of   Mitosis  in   the   so-called  Gonorrhoeal 

Wart."— .4r<f^.  of  Middx.  Eosp.,  vii.,  1906. 
Colinheim,  "  Vorlesungen  uber  allgemeine  Pathologic,"  Berlin,  1882. 

Cooper,  P.  R.,  "  On  the  Nature  and  Origin  of  Cancer  Cells." — Med.  Chron., 
Manchester,  Dec.  1900. 

Farmer,  J.  B.  (with  Moore,  J.  E.  S.,  and  Walker,  C.  E.),  "On  the  Resemblance 
exhibited  between  the  Cells  of  Malignant  Growths  in  Man  and  those 
of  the  Normal  Reproductive  Tissues." — Proc.  Hoy.  Sac,  Dec.  1903. 
"  The  Nature  of  Malignant  Growths."— .SriiJ.  Med.  Journ.,  1905, 1.  1277. 

Gaylord,  "Fourth  Annual  Report  of  the  Cancer  Laboratory,"  New  York,  1903. 

Jensen, ,"  Experimentalle  Untersuchungen  iiber  Krebs  bei  Mausen." — Centralbl. 
f.  Baoteriol.,  xxxiv.,  1903. 

Plimmer,  "  The  Parasitic  Theory  of  Cancer,  with  numerous  references." — 
Brit.  Med.  Journ.,  1903,  ii. 


CHAPTER    XXVII 
THE  TREATMENT   OF    MALIGNANT    TUMOURS 

With  our  present  limited  knowledge,  the  only  method  which 
affords  any  hopeful  prospect  to  patients  affected  with  cancer 
or  sarcoma  is  early  and  thorough  removal  of  the  affected  part, 
and  in  the  case  of  cancer  it  is  cdso  necessary  to  remove  the 
associated  lymphatics  and  lym'ph- glands. 

This  mode  of  treatment  can  be  adopted  when  the  patients 
seek  advice  at  an  early,  and  operable,  stage.  There  are  few 
organs  in  the  body  which  have  not  been  extirpated  for  this 
cause  :  e.g.  the  breast,  the  eyeball,  tongue,  larynx,  parts  of  the 
oesophagus,  thyroid  gland,  stomach,  long  sections  of  the 
intestine,  the  csecum,  and  rectum  ;  the  kidney,  penis,  testis, 
prostate,  segments  of  the  bladder,  the  ovary  and  uterus ; 
the  gall-bladder  and  portions  of  the  liver,  and  the  entire 
spleen.  There  is  nothing  in  the  way  of  surgical  ingenuity 
and  enterprise  that  has  been  left  undone,  with  the  hope  of 
affording  relief  to  those  suffering  from  malignant  tumours. 
Yet  they  baffle  surgical  art  by  their  insidious  modes  of 
growth,  their  indefinite  limitations  in  the  tissues,  and  the 
infection  of  the  l37mphatic  system,  and,  above  all,  by  their 
property  of  quiescence,  often  for  many  years,  and  then  of 
suddenly  undergoing  recrudescence  and  growing  rapidly. 

Inoperable  malignant  disease. — When  cancer  and  sar- 
coma recur  locally  after  operation,  or,  in  their  incidence, 
involve  vital  parts  which  cannot  be  subjected  to  operative 
interference,  or  affect  an  area  of  the  body  too  wide  to  permit 
of  removal,  much  can  be  done  to  make  the  patient's  life  more 
or  less  tolerable,  and  many  methods  have  been  devised  with 
the  object  of  checking  their  growth.  Some  of  these  will  be 
considered. 

Treatment  of  inoperable  cancer  of  the  breast. — When  cancer 
of  the  breast  comes  under  the  observation  of  the  suro-eon 

287 


288  EPITHELIAL   TUMOURS 

after  it  has  so  widely  iniplicated  adjacent  tissues,  or  infected 
the  associated  lymph-glands  to  such  an  extent  that  it  cannot 
be  completely  removed  by  operation  or  b}^  caustics,  it  is  said 
to  be  "  inoperable  " ;  and  the  same  term  is  applied  to  cases  in 
which  the  skin  and  internal  organs  are  the  seat  of  cancer- 
nodules,  and  in  patients  Avith  recurrent  cancer  infiltrating  the 
chest-wall,  or  implicating  the  large  blood-vessels  and  nerves 
in  the  axilla.  With  the  hope  of  doing  good  in  these  cir- 
cumstances, Sir  George  Beatson,  reasoning:  on  the  effect 
which  double  oophorectomy  is  supposed  to  exercise  on  the 
mammary  glands,  advocated  the  removal  of  the  ovaries  and 
Fallopian  tubes,  and  the  administration  of  the  extract  of 
thyroid  gland  ;  the  object  being  to  promote  and  hasten  the 
fatty  degeneration  of  the  cancer-elements. 

The  results  in  some  instances  where  bilateral  oophorec- 
tomy has  been  performed  have  been  astonishing.  In  some 
patients  the  disease  has  completely  disappeared ;  in  others  the 
disappearance  has  been  followed  by  recrudescence ;  and  in  one 
remarkable  case  under  my  own  observation  dissemination 
occurred  after  bilateral  oophorectomy,  but  the  nodules  sub- 
sequently disa]3peared.  In  many  women  the  operation  has 
temporarily  checked  the  course  of  the  disease,  but  in  the 
majority  it  has  had  absolutely  no  effect. 

Lett  (1905)  published  an  analysis  of  ninety-nine  cases 
of  carcinoma  of  the  breast  treated  by  oophorectomy,  which 
practically  confirms  these  conclusions.  He  points  out  that 
the  best  consequences  occur  when  the  patients  are  between 
the  forty-fifth  and  fiftieth  years,  and  that  the  operation 
has  a  mortality  of  6  per  cent. 

Removal  of  the  ovaries  as  a  method  of  treating  cancer 
of  the  breast  is  now  abandoned. 

Treatment  by  the  X-rays  and  radium. — Great  interest  Avas 
aroused  by  the  statement  that  the  application  of  the 
X-rays  has  a  remarkable  deterrent  effect  on  the  growth  of 
cancer.  The  matter  has  been  tested  in  the  most  determined 
way  by  very  competent  men,  and  it  may  be  stated  that  the 
effects  of  this  mode  of  treatment  are  local,  and  onl}'  affect 
deposits  of  malignant  disease  which  are  exposed.  It  is 
impossible  without  injury  to  the  skin  to  administer  a 
sufficiently  strong  exposure  to  modify  growth  in  the  viscera, 


TREATMENT  OF  GANGER  289 

although  a  moderate  exposure  relieves  deep-seated  pain. 
When  superficial  growths  are  exposed  to  the  rays,  pain  is 
usually  relieved,  growth  is  retarded,  and  retrogressive  changes 
are  induced  which  sometimes  enable  patients  to  resume  an 
active  life.     (Lyster.) 

The  judicious  exposure  of  rodent  ulcer  to  X-rays  or 
to  radium  not  only  heals  the  ulcers  but  cures  the  disease, 
and,  what  is  remarkable,  leaves  a  scar  which  resembles  the 
normal  skin  more  nearly  than  any  scar  resulting  from  a 
surgical  operation. 

Drugs  and  nostrums. — No  drugs  are  known  which  in  any 
way  retard  the  growth  of  cancer.  Periodically,  remedies  are 
vaunted  and  claimed  as  specifics  in  this  disease,  and  are  tried 
extensively  by  those  affected,  with  carcinoma.  The  drugs 
which  have  in  recent  years  claimed  attention  more  than 
others  are  Chian  turpentine  and  salicylate  of  soda ;  in  very 
exceptional  cases  some  amount  of  improvement  has  been 
noticed  in  the  rate  of  growth  of  large  exuberant  cancerous 
masses,  and  these  drugs  seem  also  to  check  the  amount  of 
discharge,  but  no  real  and  permanent  good  has  ever  been 
recorded. 

The  list  of  things  recommended  as  remedies  by  lay  persons 
to  their  friends  who  suffer  from  cancer  is  almost  inexhaust- 
ible, and  includes  powdered  oyster-shells,  violet-leaves,  and 
things  unmentionable,  as  well  as  incongruities  such  as  the 
witches  add  to  the  stew  in  the  famous  cauldron  in  the  open- 
ing scene  of  the  fourth  act  of  Macbeth. 

The  toxin  method. — It  had  often  been  observed  by  sur- 
geons that,  when  erysipelas  attacked  a  cancerous  breast, 
the  growth  of  the  cancer  appeared  to  be  checked  for  a  time. 
It  had  also  been  noticed,  especially  by  Campbell  de  Morgan,  a 
former  surgeon  of  the  Middlesex  Hospital,  that  when  a  can- 
cerous breast  had  been  removed  and  the  wound  became 
infected  with  erysipelas — a  common  event  in  those  days 
(1870) — recurrence  would  be  delayed  longer  than  in  ordinary 
circumstances.  These  things  existed  as  a  kind  of  clinical 
tradition  until  Dr.  William  Coley  traced  out  the  subsequent 
history  of  a  patient  who  had  been  under  the  care  of  Dr.  Bull 
in  the  New  York  Hospital  with  a  round-celled  sarcoma  of 
the   neck  four  times  recurrent.     Whilst  in  the  hospital   he 

T 


290  EPITHELIAL    TUMOURS 

liad  been  attacked  by  erysipelas ;  during  tliis  attack  tbe 
tumour  disappeared,  and  Coley  found  the  patient  alive  and 
well  seven  years  later  (1891).  This  gave  him  the  idea  of 
curmg  patients  with  inoperable  cancer  and  sarcoma  by 
infecting  them  with  erysipelas.  He  found  it  very  ditficult 
to  inoculate  cancerous  patients  with  erysipelas,  but  he 
succeeded  in  those  with  sarcoma.  From  observation  he 
satisfied  himself  that  the  streptococcus  was  the  toxic  prin- 
ciple. By  further  experiments  he  found  that  a  mixed  culture 
of  the  streptococcus  of  erysipelas  and  the  Bacillus  prodigiosus 
was  more  controllable.  Coley's  original  observations  were 
published  in  1891,  and  he  has  since  given  his  latest  results 
(1906)  with  a  table  of  thirty-six  cases  treated  by  himself,  and 
a  table  of  sixty  patients  in  which  the  method  has  been  carried 
out  by  other  surgeons.  The  results  in  some  instances  have 
been  brilliant. 

Some  examples  of  spindle- celled  sarcoma  disappear  by 
slow  absorption ;  but  the  highly  vascular  round-celled  type 
are  more  hkely  to  degenerate  rapidly,  with  the  formation 
of  sloughs.  The  more  vascular  the  tumour  the  more  likely 
is  the  injection  of  the  toxin  to  be  followed  by  severe  reaction, 
which  may  be  fatal. 

The  best  results  follow  in  spindle- celled  sarcomas ;  the 
method  has  had  no  permanent  result  in  melanomas.  The 
use  of  the  toxin  is  not  free  from  risk :  its  use  is  encouraging, 
but  by  no  means  certain. 

In  regard  to  the  various  methods  advocated  for  the  relief 
and  "  cure  "  of  inoperable  cancer,  it  may  be  stated  that  all  the 
methods  hitherto  proposed  are  unreliable  and  uncertam.  In 
the  majority  of  cases  they  have  no  effect  Avhatever,  and  even 
in  the  few  instances  in  which  the  treatment  has  done  good 
there  has  been  no  reliabihty  as  to  the  permanency  of  the 
improvement. 

It  is  clear  to  the  minds  of  all  thoughtful  men  that  no 
permanent  advance  can  be  made  in  the  treatment  of  this 
dire  disease  until  we  know  the  cause  of  it,  and  then  it  is 
highly  probable  that  we  may  learn  how  to  prevent  it.  The 
cause  of  cancer  and  sarcoma  remains  a  riddle,  but  let  us 
hope  that  this  riddle  is  one  which  will  be  read,  and  read 
speedily;  until  then  enthusiasts  lean  with  great  hope  to  the 


tBEATMEKT  OF  INOPERABLE   GANGER  291 

production  of  a  serum  with  sufficient  cytolytic  power  to 
induce  rapid  degeneration  of  the  specific  cells  of  these  de- 
structive tumours. 

Palliative  treatment  of  inoperable  cancer.  —  Apart  from 
any  hope  of  cure,  much  may  be  done  to  make  men's  and 
women's  lives  endurable  in  the  late  stages  of  inoperable 
cancer,  by  keeping  the  fungating  masses  clean  by  frequent 
dressing ;  by  checking  the  discharges  by  absorbent  powders 
and  amending  the  horrible  fetor  by  the  use  of  antiseptic 
solutions  and  ointments. 

The  carefid  use  of  purgatives  and  variations  in  diet  are 
often  of  very  great  importance.  The  administration  of  alcohol 
in  any  form  in  a  lavish  and  free-handed  manner  is  a  grave 
mistake,  and  as  reprehensible  as  the  unrestrained  use  ot 
morphia. 

Alcohol  taken  with  food  in  the  same  moderation  as  the 
patient  has  been  accustomed  to  in  his  usual  manner  of  life  is 
useful  and  harmless ;  and  the  administration  of  ten  or  fifteen 
grains  of  phenacetin  twice  daily  is  all  that  is  necessary,  even 
in  cases  of  great  and  severe  pain,  and  sufficient  to  give  these 
patients  comfort  and  keep  them  in  a  state  of  mind  in  which 
they  can  appreciate  the  visits  of  their  friends,  and  take  an 
intelligent  interest  in  things  around  until  death  relieves 
them. 

Beatson,  "  The  Treatment  of  Inoperable  Cancer." — Ency.  Medica,  Edin.,  vol.  xii. 
Coley,  "  Late  Eesults  of  the  Treatment  of  Inoperable  Sarcoma  by  the  Mixed 

Toxins  of  Erysipelas  and  BaciUus  prodigiosus." — Amer.  Journ.  of  Med.  Sci., 

March,  1906. 

Lett,  Hugh,  "  An  Analysis  of  Ninety-nine  Cases  of  Inoperable  Cancer  of  the 
Breast  treated  by  Oophorectomy." — Med.-CMr.  Trans.,  xxsviii.  147. 

Lyster,  Cecil  R.  C,  "  The  X-Ray  Treatment  of  Malignant  Disease." — Arcli.  of 
Middx.  Rosj}.,  1905,  v.  180. 


CHAPTER    XXVIIL 

CARCINOMA  OF  THE  BREAST 

Cancer  arises  in  connexion  with  the  glandular  elements  of 
the  mamma  in  two  situations,  namely,  in  the  acini  and  in  the 
ducts.  The  former,  the  more  frequent  and  dangerous,  is 
called  acinous  cciMcer ;  the  latter,  which  will  be  dealt  with 
in  the  next  chapter,  is  known  as  duct  cancer  of  the  breast. 

ACINOUS  CARCINOMA 

This  variety  presents  much  histological  diversity,  which 
has  led  to  great  confusion  in  surgical  writings.  In  the 
most  typical  form  it  occurs  as  a  solitary  hard  tumour, 
situated  at  the  base  of  the  nipple ;  but  it  may  occur  at  any 
part  of  the  gland,  even  at  its  periphery.  When  the  tumour 
is  near  the  areola  it  will  often  induce  retraction  of  the 
nipple ;  when  situated  in  other  parts  of  the  breast  it  will 
lead  to  dimpling  and  puckering  of  the  overlying  skin. 

On  section  such  a  tumour  has  the  appearance  and  consist- 
ence of  an  um-ipe  pear ;  microscopically,  it  will  be  found  to 
consist  of  columns  of  epithelial  cells,  disposed  like  the  lobules 
of  the  gland,  and  embedded  in  dense  fibrous  tissue.  The 
tumour  has  no  capsule,  and  fades  away  indefinitely  into  the 
surrounding  tissues.  When  the  parts  beyond  the  tumour  are 
examined,  isolated  collections  of  cells  will  often  be  detected. 

In  other  cases  the  tumour  is  only  moderately  firm, 
and  on  section  exhibits  a  succulent  appearance.  When 
microscopically  examined,  it  presents  alveolar  spaces  lined 
with  epithelium,  here  and  there  raised  into  irregularly  shaped 
heaps.  Such  a  tumour  is  difl&cult  to  distinguish  from  an 
adenoma ;  but  when  the  sections  are  attentively  examined, 
parts  will  be  found  in  which  the  alveoli  are  completely  filled 
with  irregularly  shaped  epithelial  cells. 

292 


GANGER   OF  THE  BREAST 


J93 


In  many  examples  of  mammary  cancer  the  tumour,  when 
bisected,  appears  to  the  naked  eye  merely  like  a  tract  of  cica- 
tricial tissue,  and  feels  as  hard  as  cartilage ;  when  examined 
microscopically,  it  will  be  found  to  consist  of  strands  of  fibrous 
tissue  enclosing  here  and  there  a  few  epithelial  cells.  This 
variety  is  sometimes  spoken  of  as  "  withering  "  or  contracting 


Fig.  156. — Cancerous  breast  in  section  :  the  clotted  line  indicates  the  extent 
to  which  the  nipple  and  areola  have  retracted. 

cancer;  it  runs  a  much  slower  course  than  the  preceding 
kinds,  and  gradually,  by  its  contraction,  causes  the  gland  to 
shrivel,  so  that  at  length  the  patient  presents  an  appearance 
as  if  the  breast  had  been  removed.  Some  of  these  cases  have 
been  known  to  last  twenty  years. 

Among  unusual  forms  of  cancer  ol  the  breast  may  be 
classed   the   rare   condition  in   which   it   arises  in  a  super- 


294  EPITHELIAL   TUM0UB8 

numerary  mamma  situated  in  the  axilla.  The  best-described 
example  of  this  we  owe  to  Paul. 

Clinical  features. — Acinous  cancer  of  the  breast  is  never 
manifest  before  puberty,  and  is  rare  before  the  age  of  30 ;  it 
is  most  common  between  40  and  50  ;  after  50  it  gradually 
becomes  less  frequent,  and  it  is  rare  after  70.  I  have  seen  it 
in  a  woman  90  years  of  age. 

This  variety  of  breast-cancer  occurs  in  the  single  as  well 
as  the  married;  in  the  sterile  as  well  as  in  those  who  have 
had  many  children ;  in  women  who  have  nursed  their  off- 
spring and  in  those  who  have  never  given  suck.  It  also 
attacks  the  male  breast.  Mammary  cancer  is  one  hundred 
times  more  frequent  in  women  than  in  men.  Concurrent 
primary  cancer  of  both  breasts  is  not  unknown,  but  it  is 
unusual. 

It  is  an  important  and  well-established  fact  that  cancer  is 
more  prone  to  attack  a  breast  that  has  been  the  seat  of  previ- 
ous disease  (mastitis)  than  one  that  is  obviously  healthy,  and 
Sir  William  Mitchell  Banks  emphasized  the  importance  of 
appreciating  this  fact  in  regard  to  successful  treatment. 

Cancer  usually  attracts  attention  as  a  circumscribed  hard 
lump  in  the  mamma  ;  it  never  forms  a  large  tumour — indeed, 
a  mammary  cancer  rarely  exceeds  the  dimensions  of  a  fist. 
The  rate  of  growth  may  be  slow,  often  extremely  slow, 
especially  in  old  individuals.  When  cancer  appears  during 
lactation  it  progresses  with  frightful  rapidity. 

As  the  tumour  increases  in  size  it  infiltrates  surrounding 
tissues,  becomes  adherent  to  the  fascia  of  the  pectoral  muscle, 
and  even  implicates  the  muscle.  These  infiltrated  tissues 
shrink  and  cause  the  cancerous  breast  to  become  smaller, 
often  much  smaller,  than  its  fellow  (Fig.  156).  The  general 
shrinking  ~of  the  breast  is  an  important  factor  in  diagnosis, 
and  must  not  be  confounded  with  retraction  of  the  nipple, 
which  is  rarely  of  diagnostic  import,  as  it  occurs  under  a 
variety  of  conditions. 

Lymph-gland  infection  occurs  early  in  cancer,  and  is  an 
important  cHnical  sign.  The  glands  of  the  axilla  which  run 
parallel  with  the  free  border  of  the  greater  pectoral  are  first 
affected,  but  the  infection  quickly  extends  to  and  involves 
the  whole  set,  and  in  later  stages  the  glands  lying  in  the 


GANGER   OF  THE  B  BE  AST  295 

posterior  triangle  of  the  neck  immediately  above  the  clavicle 
enlarge. 

It  by  no  means  follows  that  because  a  tumour  of  the 
breast  is  unassociated  with  large  lymph-glands  the  tumour  is 
not  a  cancer.  By  the  time  the  glands  are  sensibly  enlarged 
the  tumour  has  made  its  way  towards  the  surface,  and  at  last 
the  involved  skin  ulcerates.  The  advent  of  ulceration  is 
heralded  by  a  purplish  or  bluish  appearance  of  the  skin,  which 
sometimes  resembles  a  recent  cicatrix  with  veins  radiating 
from  it,  or  the  surrounding  skin  may  be  dotted  with  small 
knots  of  the  size  of  a  split  pea,  or  even  larger. 

After  the  skin  breaks,  the  ulcer  tends  to  spread,  and  soon 
assumes  the  typical  appearance  of  a  cancerous  ulcer :  its  edges 
are  raised  and  rampart-like,  and  surround  an  irregular 
depression,  the  floor  of  which  is  formed  of  firm  granulations, 
discharging  a  foul  ichorous  or  blood-stained  fluid. 

Pain. — There  is  no  symptom  more  variable  in  mammary 
cancer  than  pain.  A  large  proportion  of  patients  experience 
no  painful  sensations  whatever,  and  are  absolutely  ignorant  of 
the  presence  of  any  disease  in  the  breast  until  their  attention 
is  arrested  by  some  irregularity  in  its  outline,  or  some  marked 
difference  in  the  comparative  size  of  the  two  breasts.  In  some 
the  pain  is  localized,  but  in  others  it  radiates  from  the  tumour 
to  the  surrounding  parts.  The  pain  in  mammary  cancer  is 
usually  a  concomitant  of  the  late  stages  of  the  disease.  Path- 
ology has  totally  failed  to  furnish  an  explanation  why,  in 
two  patients  of  about  the  same  age,  temperament,  and  char- 
acter, each  having  a  tumour  in  the  breast  in  corresponding 
situations,  and  in  structure  identical,  one  should  suffer 
anguish  too  terrible  to  describe,  and  the  other  be  absolutely 
free  from  pain,  and  often  devoid  of  any  feeling  of  discomfort. 

Concurrently  with,  but  more  often  subsequently  to,  infec- 
tion of  the  lymph-glands,  secondary  deposits  occur  in  the 
viscera,  especially  the  liver  and  lung ;  but  any  organ  may  be 
the  seat  of  deposit. 

When  the  liver  is  attacked  it  enlarges,  and  there  may  be 
hydroperitoneum,  rarely  jaundice;  deposits  in  the  lungs  and 
pleurae  set  up  pneumonia  and  pleurisy.  When  effusions  occur 
in  the  pleurae,  peritoneum,  or  pericardium,  as  a  result  of 
cancerous  infection,  the  fluid  is  often  blood-stained. 


296  EPITHELIAL   TUMOVES 

Secondary  deposits  in  the  brain  give  rise  to  mental  disturb- 
ance and  coma.  Deposits  in  tbe  bones  cause  "  spontaneous  " 
fracture,  and  when  the  vertebral  column  is  implicated  para- 
plegia, preceded  by  acute  suffering,  is  the  usual  consequence. 
Enlarged  glands  and  secondary  deposits  may  so  involve  large 
vessels  and  lymphatic  trunks  in  the  axilla  as  to  produce  solid 
oedema  of  the  arm. 

It  must  also  be  remembered  that  in  the  late  stages  of  the 
disease  the  tissues  covering  the  thorax  may  be  infiltrated,  and 
this  local  exteasion  may  implicate  the  ribs  and  directly  infect 
the  pleura. 

In  some  patients,  secondary  deposits  of  mammary  cancer 
occur  as  a  multitude  of  small  nodules  in  the  skin  covering 
the  front  of  the  chest  and  both  breasts,  and  induce  such 
induration  of  the  skin  that  it  becomes  so  rigid  as  to  resemble 
a  firm  leather  shield,  a  condition  which  has  earned  for  it  the 
name  of  "  cancer  en  cuirasse."  In  this  extreme  condition  the 
skin  is  so  firm  and  hard  (pig-skin)  that  it  is  impossible  to 
wrinkle  it.  This  peculiar  condition  is  probably  due  to  cancer- 
ous invasion  of  the  cutaneous  lymphatics. 

As  the  cancer  extends  locally  and  ulcerates,  and  more 
especially  when  there  is  evidence  of  secondary  deposits,  the 
patient's  health  begins  rapidly  to  decline  and  the  tissues 
to  waste.  It  is  astonishing  how  women  with  breasts  in- 
filtrated with  cancer,  or  eroded  by  large  and  foul  ulcers, 
will  sometimes  be  able  to  get  about  and  busy  themselves 
with  household  matters ;  and  this  state  of  things  will 
continue  for  many  months,  perhaps  until  the  supervention 
of  pleurisy,  pneumonia,  or  some  complication  due  to  the 
dissemination  of  the  cancer  incapacitates  them  and  ex- 
tinguishes life. 

Lymphatic  OBdema. —  This  occasional  complication  of 
mammary  cancer  must  be  considered,  on  account  of  the 
inconvenience  and  distress  it  produces.  It  is  a  condition 
which  cannot  be  mistaken.  The  oedema  usually  becomes 
manifest  in  the  skin  about  the  shoulder,  gradually  extends 
to  the  skm  of  the  arm,  and  in  due  course  involves  the 
forearm  and  hand ;  the  skin  covering  the  scapula  is  also 
implicated.  The  limb  in  typical  cases  has  a  swollen  appear- 
ance, as  though  anasarcous ;  but  when  the  skin  is  pressed. 


GANGER  OF    THE  BREAST 


297 


instead  of  pitting  on  pressure  it  will  be  found  firm,  brawny 
and  unyielding. 

The  limb  grows  extremely  heavy,  and  the  patient  finds  it 
necessary  to  support  it  in  a  sling.  Exceptionally  the  weight  of 
the  limb  prevents  the  patient  from  taking  walking  exercise ; 


Fig.  157.— Cancer  en  cuirasse  with  oedema  of  the  arm. 

it  usually  produces  a  moderate  degree  of  lateral  curvature 
of  the  spine.  The  connective  tissue  may  be  so  infiltrated 
with  lymph  that  the  skin  becomes  sufficiently  tense  to 
prevent  movement  at  the  wrist,  elbow,  and  shoulder :  under 
such  conditions  the  arm  resembles  a  wax  cast  rather  than 
a  Hving  limb,  and  is  absolutely  useless. 


298  EPITHELIAL   TUMOURS 

When  the  tissues  of  such  a  limb  are  examined  immediately- 
after  death,  it  will  be  noticed  that  the  increase  in  size  is  due 
to  infiltration  of  the  subcutaneous  tissue  with  lymph,  which 
causes  the  cut  surface  to  resemble  in  colour  and  in  texture 
the  pulp  of  a  succulent  orange,  and  large  quantities  of  lymph 
flow  from  the  incisions.  The  muscles  are  smaller  than  natural 
and  infiltrated  with  fat.  In  the  character  of  the  fluid  which 
exudes  from  the  limb,  and  in  the  firmness  of  the  infiltrated 
connective  tissue,  it  resembles  the  oedema  characteristic  of 
myxcedema. 

In  the  condition  we  are  considering,  the  obstruction  to  the 
lymphatic  circulation  of  the  upper  limb  is  due  to  the  pressure 
of  lymph-glands  infiltrated  with  cancer,  or  to  secondary 
nodules  lying  in  the  course  of  the  main  lymphatic  channels 
at  the  apex  of  the  axilla.  Exceptionally  it  complicates  the 
form  of  cancerous  dissemination  known  as  cuirass  cancer. 

Lymphatic  oedema  of  the  upper  limb  may  supervene  in 
patients  with  cancerous  breasts  who  have  never  been  sub- 
mitted to  operation,  in  those  in  whom  the  axillary  lymph- 
glands  were  removed  when  the  breasts  were  amputated,  and 
in  those  whose  axillae  were  not  interfered  with.  Many  more 
cases  have  come  under  my  notice  in  the  right  than  in  the 
left  arm.  Pain  is  experienced  in  the  limb  by  most  of  the 
patients,  and  it  is  often  very  severe.  This  is  due  not  to 
the  oedema,  but  to  the  enlarged  glands  or  cancerous  nodules 
pressing  on  the  cords  of  the  brachial  plexus  or  their  branches. 

Treatment. — With  our  present  knowledge,  the  only  method 
of  treatment  which  offers  any  hopeful  prospect  to  individuals 
affected  with  mammary  cancer  consists  in  the  removal  of  the 
whole  breast  with  its  outlying  lobules,  of  the  skin  overlying 
the  breast,  the  pectoral  muscle  with  its  fascia,  the  lymphatics 
which  run  from  the  breast  to  the  axilla,  and  the  axillary 
lymph-glands.  Handley,  who  has  carefully  investigated  the 
serpiginous  way  in  which  the  cancer-cells  permeate  the  deep 
fascia,  advises  the  wide  removal  of  this  fascia,  especially  in 
the  direction  of  the  epigastric  region,  in  order  to  prevent 
the  cancerous  invasion  of  the  abdomen. 

Unfortunately  the  chief  difficulty  the  surgeon  finds  in 
recommending  this  very  clumsy  though  appropriate  remedy 
arises  from  the  circumstance  that  patients  so  often  conceal 


GANGER   OF   THE  BREAST  299 

the  fact  tliat  they  have  a  tumour  until  compelled  by  pain, 
discomfort,  and  often  actual  misery,  induced  by  ulceration 
and  sloughing  of  the  cancer,  to  seek  advice.  There  is,  of 
course,  a  small  proportion  of  women  who  absolutely  refuse  to 
submit  to  operation  in  the  early  hopeful  stages,  and  wait  until 
the  skin  becomes  involved  before  they  realize  their  unfortun- 
ate condition.  When  the  tumour  has  been  allowed  to  run  its 
course  and  infect  the  axillary  lymph-glands  or  ulcerate,  the 
chance  of  doing  good  by  operation  is  seriously  diminished. 

Careful  observations  show  clearly  enough  that  those 
patients  do  best  who  have  the  cancerous  mamma  extirpated 
at  the  earliest  possible  date  after  the  tumour  is  perceived. 
There  is  a  consensus  of  opinion  among  surgeons  who  have 
had  the  largest  experience  in  cancer  that  when  a  patient 
comes  under  observation  with  a  nodule  in  the  mamma  which 
it  is  reasonable  to  regard  as  cancerous,  it  is  the  duty  of  the 
medical  attendant  to  advise  the  removal  of  the  breast.  It 
is,  however,  a  remarkable  fact  that  while  mammary  tumours, 
innocent  and  malignant,  have  been  subject  to  observation  for 
centuries,  there  is  no  organ  in  the  body  in  which  tumours 
give  rise  to  more  doubt  or  difficulty  in  diagnosis  than  in 
the  mamma.  This  is  so  generally  recognized  that  it  is  the 
duty  of  every  surgeon,  before  amputating  a  breast,  to  make 
an  incision  into  the  swelling,  in  order  to  assure  himself  that 
he  is  really  dealing  with  a  malignant  tumour  and  not  a 
simple  cyst,  abscess,  or  localized  inflammation. 

The  most  favourable  cases  are  those  in  which  the  cancer  is 
limited  to  the  breast,  does  not  involve  the  skin,  and  has  not 
produced  any  appreciable  enlargement  of  the  axillary  lymph- 
glands.  In  such  a  case  the  removal  of  the  whole  breast,  with 
the  underlying  fascia,  lymphatics  and  lymph-glands,  is  a  pro- 
ceeding which,  if  properly  carried  out,  is  devoid  of  operative 
risks :  recurrence  or  dissemination  is  indefinitely  delayed,  and 
the  patient  may  enjoy  many  years  (five,  ten,  or  even  fifteen) 
of  useful  life. 

When  the  cancer  has  been  allowed  to  implicate  the  skin,  or 
has  ulcerated,  and  there  is  extensive  infection  of  the  lymph- 
glands,  then  very  wide  removal  of  the  tissues  is  imperative. 
This  necessarily  adds  to  the  risks  of  the  operation ;  and  though 
in  many   instances   patients    have   allowed    the    disease    to 


300  EPITHELIAL   TUMOURS 

advance  in  tMs  way  before  coming  to  tlie  surgeon,  yet  a  fair 
proportion  enjoy  some  years  of  immunity  from  recurrence, 
but  their  expectation  of  life  is  not  great.  The  difficulty  the 
surgeon  has  to  contend  with  in  this  stage  is  uncertainty  of 
the  presence  of  secondary  nodules  in  the  viscera. 

When  cancer  of  the  breast  extensively  involves  the  skin 
and  has  ulcerated  deeply — and  especially  if  it  implicates  the 
pectoral  muscle  and  chest  wall — then  operation  is  useless. 

Although  it  is  extremely  difficult  to  indicate  even  approxi- 
mate rules  as  to  the  advisability,  or  otherwise,  of  operating  in 
certain  conditions  of  mammary  cancer,  there  are  cases  in 
which  it  can  be  definitely  laid  down  that  operations  are 
useless.     For  instance : — 

1.  When  the  supraclavicular  lymph-glands  are  enlarged. 

Such  extensive  infection  of  lymph-glands  indicates 
that  the  mediastinal  set  is  probably  involved. 

2.  When  a  large  area  of  skin  is  implicated,  and  particu- 

larly in  cases  where  it  is  brawny  or  beset  with  small 
nodules  (cuirass  cancer). 

3.  In  every  case  where   there  is   reason   to   believe  that 

dissemination  has  occurred. 

Perhaps  one  of  the  most  extraordinary  facts  connected 
with  mammary  cancer  is  this :  Two  patients  may  have  their 
breasts  removed  for  cancer ;  they  may  be  alike  in  age,  habit  of 
body,  and  circumstances ;  the  tumours  may  be  alike  as  far  as 
eyes,  fingers,  and  microscopes  can  determine;  the  operations 
may  be  conducted  by  the  same  surgeon  and  by  the  same 
method  ;  yet  one  patient  may  die  in  a  few  months  with  wide 
dissemination,  and  the  other  may  be  spared  ten  or  even  fifteen 
years.  Herein  lies  all  our  difficulty,  for  the  surgeon,  however 
wide  his  experience,  cannot  forecast  from  the  clinical  character 
of  the  tumour  the  future  of  his  patient;  neither  can  the 
morbid  histologist  predict  the  course  of  the  case.  Even  when 
a  competent  knowledge  of  surgery  and  pathology  has  been 
combined  in  an  individual  operator,  he  rarely  ventures  to 
prophesy.  It  may  be  truly  said  that  some  cases  for  which 
surgery  seemed  to  promise  much  have  been  tragic  failures, 
and  that  some  which  seemed  almost  hopeless  have  given  admir- 
able results  after  operation.     This  state  of  things  is  not  due  to 


GANGER  OF   TEE  BREAST  301 

any  supineness  on  the  part  of  pathologists,  for,  as  Rindfleisch 
has  so  pertinently  written,  "The  tumours  of  the  female 
mammary  gland  have  been  so  often,  and  already  at  so  early  a 
period,  the  subject  of  earnest  histological  investigation,  that  in 
this  sense  we  might  not  improperly  call  the  mammary  gland 
the  nurse  of  pathological  histology." 

It  has  already  been  mentioned  that  cancer  rarely  attacks 
both  breasts ;  it,  however,  occasionally  happens  that,  after  one 
breast  has  been  removed  for  cancer,  the  disease  appears  in 
the  other. 

Recurrence. — It  is  now  clearly  established  that  local 
recurrence  after  removal  of  a  cancerous  breast  is  due  to  two 
causes,  namely,  incomplete  removal  and  cancer-infection.  In 
respect  to  imperfect  operations.  Sir  Benjamin  Brodie,  many 
years  ago,  wrote  in  regard  to  the  removal  of  the  whole  breast : 
"  You  may  imagine  this  is  a  very  easy  thing  to  be  done,  but  it 
is  not  so  easy  in  reality ;  for  in  amputating  the  breast  you  will 
be  very  apt,  in  a  thin  person,  if  you  are  not  very  careful,  to 
leave  small  slices  of  the  gland  of  the  breast  adherent  to  the 
skin,  and  I  have  no  doubt  that  the  part  or  parbs  thus  left 
behind  in  some  cases  have  formed  the  nidus  of  future  disease." 
We  now  know  this  to  be  perfectly  true.  I  have,  in  several 
instances,  carefully  examined  microscopically  small  recurrent 
nodules,  and  found  them  associated  with  small  fragments  of 
gland-tissue.  A  more  serious  form  of  recurrence  is  due  to 
insufficient  removal  of  the  overlying  skin ;  in  this  event,  after 
the  wound  has  healed,  the  skin  around  the  cicatrix  is  often 
converted  into  a  hard,  brawny  plaque. 

Sometimes  the  surgeon  removes  a  cancerous  breast,  takes 
every  care  to  keep  wide  of  the  tumour  in  making  the  skin- 
incision,  dissects  out  the  gland-tissue,  removes  the  major  and 
minor  pectorals,  and  clears  the  lymph-glands,  with  the  sur- 
rounding fat,  from  the  axilla.  He  closes  the  wounds,  and 
congratulates  himself  on  the  completeness  of  the  operation. 
Occasionally  his  industry  is  rewarded,  but  now  and  then  these 
extensive  enterprises  are  followed  by  rapid  and  wide  recur- 
rences, which  often  take  the  form  of  infiltration  of  the  skin 
raised  in  the  operation  and  of  the  underlying  chest- wall.  This 
dire  result  is  due  to  the  distribution  of  cancer-cells  in  the 
course  of  the  operation ;  in  short,  to  cancer-infection  {see  p.  270). 


302  EPITHELIAL   WMOUHS 

The  practice  followed  by  many  surgeons  of  rudely  pulling 
out  tlie  axillary  lymph-glands  one  by  one,  especially  if  they 
be  cancerous,  is  very  liable  to  infect  the  connective  tissue 
of  the  armpit,  and  lead  to  the  formation  of  a  hard,  brawny 
induration  of  the  axillary  tissues. 

For  a  long  time  I  have  been  particularly  careful,  in  clear- 
ing out  the  axilla  when  extirpating  the  mamma  for  carcinoma, 
to  treat  the  adipose  tissue  with  its  lymphatics  and  embedded 
lymph-glands  as  if  they  were  one  organ,  and  dissect  these 
tissues  from  the  chest- wall  with  great  care.  The  remote  con- 
sequences of  this  proceeding  have  been  very  gratifying. 

Broadly  reviewing  the  whole  subject  of  operation  for  the 
relief  of  cancer,  we  must  admit  that  our  present  mode  of 
treating  it,  namely,  "to  cut  out  the  diseased  organ  or  part 
affected,"  though  extremely  clumsy,  is  the  only  effectual 
method  yet  debased. 

Banks,    Sir  William   Mitchell,    "  Practical   observations    on   Cancer   of   the 
Breast."— Tra/is.  of  Med.  Soc,  1900,  xxiii.  146. 

Brodie,  Sir  Benjamin.—"  Collected  Papers." 

Handley,  W.  Sampson,  "  On  the  mode  of  spread  of  Breast-Cancer  in  relation 
to  Operative  Treatment." — Glasgow  Med.  Journ.,  Dec.  1905. 

Paul,  "  Cancer  of  Axillary  Skin  Glands." — Trans.  Path.  Soc,  Ivi.  153. 


CHAPTER  XXIX 
CARCINOMA   OF  THE  BREAST  (Concluded) 

DUOT-PAPILLOMA  AND   DUCT-CARCINOMA 

Towards  the  approach  of  the  menopause  the  breast  enters 
upon  a  resting  stage ;  its  glandular  structures  shed  their  epi- 
thelium, atrophy,  and  nothing  but  ducts  remain. 

Breasts  in  this  condition  often  present  on  their  deep  sur- 
faces large  numbers  of  cysts  varying  in  size  from  a  mustard- 
seed  to  a  cherry.  These  are  frequently  called  involution  cysts, 
and  are  filled  with  mucous  fluid  which  causes  them  to  assume 
a  bluish  tint  when  the  breast  is  examined  after  its  removal 
from  the  body.  The  cysts  are  most  abundant  on  the  deep 
surface  of  the  gland. 

Cystic  breasts  of  this  kind  are  most  frequently  met  with 
between  the  forty-fifth  and  fifty-fifth  years.  In  sterile  women 
they  occur  somewhat  earlier,  and,  as  a  rule,  both  breasts  are 
affected.  When  cystic  disease  of  this  nature  is  more  advanced 
in  one  breast  than  the  other,  it  is  apt  to  be  mistaken  for 
diffuse  cancer.  This  variety  of  cystic  disease  is  often  accom- 
panied with  pain.  Cystic  mammary  glands  of  this  character 
require  attentive  study,  because  the  walls  of  the  dilated 
ducts  are  occasionally  the  starting-points  of  cancer.  In  rare 
instances  villous  processes,  or  papillomas,  sprout  from  the 
walls  of  such  cysts,  particularly  when  the  cysts  represent 
dilated  lacteal  sinuses. 

When  cancer  arises  in  dilated  mammary  ducts,  it  is  cus- 
tomary to  speak  of  it  as  "  villous  or  duct-cancer  of  the  breast." 
It  is  a  rare  variety  of  disease,  and  runs  a  less  malignant  course 
than  the  common  or  acinous  type  of  mammary  carcinoma. 

In  describing  adenomas  and  cysts  of  the  breast,  it  was 
pointed  out  that  a  galactophorous  duct  not  infrequently  dilates 
and  forms  a  cyst  of  some  size,  and  occasionally  the  terminal  duct 

303 


304 


EPITHELIAL   TUM0UB8 


by  whicli  it  opens  on  the  nipple  becomes  patent  and  allows  the 
pent-iip  fluid  to  escape  from  time  to  time.  The  close  relation 
of  these  cysts  to  the  nipple,  and  the  possibility  of  obtaining 
fluid  by  gentle  pressure,  are  valuable  diagnostic  signs. 

The  epithelial  processes  or  warts  that  may  sprout  from 
some  part  of  the  cyst- wall  of  these  cysts  are  occasionally  so 


Fig.  158. — Section  of  a  mamma  with  a  dilated  duct  filled  with  villous  papilloma. 
The  nipple  is  inverted,  not  retracted.      (From  a  woman  68  years  of  age.) 

vascular  that  they  bleed  easily,  and  then  the  fluid  escaping 
from  the  cyst  is  tinged  with  blood.  The  warty  growths  in 
such  cysts  may  be  firm  and  not  bleed ;  in  others,  when  they 
are  very  vascular,  they  resemble  in  colour  and  shape  a  ripe 
mulberry,  projecting  into  the  cyst.  Rarely  they  sprout  so 
luxuriantly  as  to  fill  the  cyst  with  delicate  papillomatous 
processes  like  the  villous  papilloma  so  common  in  the 
urinary  bladder.     The  specimen  depicted  in   Fig.  158  illus- 


DUCT  GANGER   OF   THE  BREAST  305 

trates  this.  I  removed  this  breast  from  a  woman  68  years 
of  age ;  before  the  operation  it  formed  a  tumour  as  large  as  a 
ripe  plum,  and  of  the  same  colour,  by  the  side  of  the  nipple, 
and  the  blood-stained  fluid  exuded  in  such  quantity  as 
to  soak  her  clothes  and  compel  her  to  seek  relief  Struc- 
turally, these  villous  processes  resemble  vesical  papillomas,  and 
this  explains  the  readiness  with  which  they  bleed.  A  villous 
papillomatous  cyst  has  been  observed  in  the  breast  of  a  boy, 
and  the  specimen  is  preserved  in  the  museum  of  St.  Bartholo- 
mew's Hospital.     (See  also  Robinson.) 

The  essential  histological  difference  between  a  wart  and  a 
cancer  is,  that  in  the  wart  or  papilloma  the  epithelium  merely 
covers  its  surface,  whereas  in  a  cancer  it  dips  into  the 
subjacent  tissue.  Clinical  observations  long  ago  taught  sur- 
geons that  warts  are  liable  to  become  the  starting-points  of 
cancer,  and  the  microscope  has  shown  that  this  is  due  to  the 
epithelium  at  the  base  of  the  papilloma,  instead  of  remaining 
restricted  to  the  surface,  invading  the  underlying  tissues, 
and  thus  becoming  malignant.  The  cause  of  this  invasiveness 
or  aggressiveness  we  do  not  know,  but  it  is  the  essence  of 
malignancy  as  typified  in  cancers.  The  warts  in  papillo- 
matous cysts  of  the  breast  behave  like  warts  on  the  skin  in 
this  respect,  and  the  result  is  what  surgeons  term  "duct- 
cancer."  It  must  not  be  inferred  from  this  that  duct-cancer 
is  to  be  regarded  as  always  beginning  as  a  villous  papilloma 
subsequently  becoming  cancerous ;  it  is  quite  certain  that  the 
disease  may  begin  as  a  soft,  smooth,  round  bud  on  the  wall  of 
a  cyst  without  the  least  suggestion  of  a  villous  or  a  warty 
surface,  but  this  bud  contains  epithelium-lined  spaces.  The 
specific  character  of  duct-cancer  of  the  breast  is  this :  the 
cancerous  nodule  is  contained  in  a  cyst.  It  is  also  note- 
worthy that  in  two  patients  in  whom  recurrence  occurred  after 
amputation  of  the  breast — a  rare  sequel  in  this  species  of 
cancer — the  recurrent  nodules  took  the  form  of  cysts  the  size 
of  cherries,  and  each  cyst  contained  a  soft,  sessile,  purple  wart 
bathed  in  blood-stained  fluid,  so  that  when  the  cysts  were 
exposed  in  the  course  of  removal,  they  resembled,  in  colour, 
melanotic  nodules. 

Metastasis  or  dissemination  of  duct-cancer  is  rare.     I  have 
never    seen    an    example.      Shattock    made   an    interesting 
u 


306  EPITHELIAL   TUMOURS 

observation  in  relation  to  this :  he  found  in  the  museum  a  rib 
preserved  on  account  of  a  secondary  nodule  of  cancer  which 
it  contained.  On  microscopic  examination  this  nodule  pre- 
sented the  characters  of  a  duct-cancer  of  the  breast.  The  his- 
tory of  the  case  was  consulted,  and  it  contained  the  statement 
that  the  patient,  a  woman  aged  60  years,  had  suffered  amputa- 
tion of  the  breast,  a  few  weeks  before  her  death,  on  account  of 
a  tumour  it  contained.  "  It  is  recorded  that  the  breast  was 
generally  believed  to  be  scirrhous,  but  that  some  of  those  who 
saw  it  had  doubts  on  the  point." 

In  the  majority  of  instances  duct-cancer  appears  as  a 
solitary  tumour  in  the  breast  near  the  nipple,  usually  of  the 
size  of  a  walnut,  but  it  may  reach  the  size  of  a  large  ripe 
orange  :  exceptionally,  two  or  more  independent  lumps  may 
be  present.  There  is  no  retraction  of  the  nipple,  nor  implica- 
tion of  the  skin. 

Clinical  features. — Duct-papilloma  and  duct-cancer  ap- 
pear most  frequently  between  the  ages  of  35  and  65.  The 
tumour  is  always  softer  than  in  the  common  or  acinous 
variety.  When  seated  near  the  skin  it  assumes  a  dark- 
red  or  even  purple  tint,  and  has  even  been  mistaken  for 
a  melanoma.  The  nipple  is  not  retracted,  but  may  be 
inverted  (Fig.  158).  This  is,  however,  a  sign  of  no  value. 
In  a  very  large  proportion  of  cases  there  is  an  abundant 
discharge  of  blood-stained  fluid  from  the  nipple.  The  tumour 
grows  very  slowly,  rarely  implicates  the  lymph- glands,  and 
exhibits  very  little  tendency  to  recur  or  to  become  dissemi- 
nated.    It  is  the  least  malignant  variety  of  mammary  cancer. 

Treatment. — This  consists  in  the  free  removal  of  the 
breast  and  the  associated  lymphatics  and  the  axillary  lymph- 
glands,  as  well  as  the  pectoral  fascia.  The  results  of  this  form 
of  treatment,  immediate  and  remote,  are  admirable. 

Battle,  W.,  Trans.  Path.  Soc,  xxxix.  322. 

Bland-Sutton,  J.,  Trans.  Path.  Soc,  xliii.  117. 

Bowlby,  A.  A.,  St.  Bart.'s  Hosp.  Repts.,  xxiv.  263. 

Godiee,   R.   J.,    "An   Anomalous   Form  of  Blood  Cyst." — Trans.  Path.  Soc, 

xxxvii.  270. 
Pitts,  B..  Ibid.,  xxxix.  320. 
Pollard,  Bilton.,  Ibid.,  xxxvii.  483. 

Robioson,  Betham,  "  Duct  Carcinoma  of  the  Male  Nipple." — Ibid.,  xli.  227. 
Shattock,  S.  J.,  Ibid.,  xxxix.  324. 


CHAPTER    XXX 

EPITHELIAL  TUMOURS   OF   HAIR-FOLLICLES; 
SEBACEOUS  GLANDS ;  AND  RODENT  CANCER 

TuMOUKS  connected  with  sebaceous  glands  are :  1,  Seba- 
ceous cysts,  or  wens  ;  2,  sebaceous  adenomas. 

1.  Sebaceous  cysts  (Avens). — The  sebum  resultmg  from 
the  activity  of  a  sebaceous  gland  escapes,  as  it  is  formed,  on 
to  the  free  surface.  Should  the  orifice  of  the  follicle  become 
occluded,  the  secretion  is  retained,  and  the  glandular  acini, 
becoming  distended,  give  rise  to  an  appreciable  swelling 
known  as  a  sebaceous  cyst.  This  is  the  usual  description  of 
the  mode  by  which  these  cysts  arise;  but  even  a  superficial 
examination  of  a  number  of  sebaceous  cysts  will  serve  to  show 
that  in  many  there  is  no  obvious  obstruction — indeed,  the 
duct  may  be  widely  open  and  the  sebum  exuding,  so  that 
obstruction  of  the  duct  is  not  an  explanation  that  will  cover 
all  cases.  Shattock  has  shown  that  the  common  "  wen,"  in 
most  instances,  arises  in  a  hair-follicle. 

It  has  long  been  known  that  the  sebaceous  follicles  often 
contain  one  or  more  examples  of  the  Beinodex  folliculoruin- 
It  is  usually  stated  that  these  arachnids  are  harmless,  and 
their  presence  merely  an  epiphenomenon.  A  good  account 
of  this  demodex  is  given  by  Thudichum. 

These  cysts  occur  in  all  situations  where  sebaceous  glands 
abound;  an  exceptionally  common  place  is  the  scalp.  The 
cyst  may  be  single ;  sometimes  many  are  present — indeed, 
sixteen  or  more  may  be  counted  on  one  scalp.  In  size  they 
vary  greatly :  many  are  as  large  as  walnuts ;  others  are  of  the 
size  of  peas  ;  they  are  rarely  bigger  than  Tangerine  oranges. 

In  most  situations  sebaceous  cysts  are  readily  recognized, 
as  they  are  distinctly  circumscribed  and  lodged  in  the  skin. 
On  the  surface  of  sebaceous  cysts  occurring  in  any  part  of  the 
trunk  and  head  save  the  scalp,  close  scrutiny  will  reveal  either 

307 


308 


EPITHELIAL   TUMOURS 


a  black  dot  or  a  small  dimple.  This  is  the  orifice  of  the 
follicle,  and  on  picking  off  the  black  spot  and  squeezing  the 
cyst,  sebum  will  exude,  and  thus  furnish  positive  evidence  of 
the  nature  of  the  cyst.  It  is  a  curious  fact  that  in  wens  of 
the  scalp  the  orifice  is  rarely  seen,  exce]3t  those  which  occur 
along  the  junction  of  the  skin  of  the  forehead  with  the  hairy 
scalp.  A  sebaceous  cyst,  unless  it  has  been  inflamed,  is  easily 
shelled  out  of  its  matrix.  It  then  presents  a  capsule  and 
contents.     The  capsule  may  be  exceedingly  thin  and  pliant, 


Sl.-^; 


Fig.  159. — Sebaceous  glands  in  the  velvet  of  the  antler  of  a  stag  [Cervus  elaphiis). 

the  inner  surface  presenting  an  epithelial  lining ;  or  it  may  be 
laminated,  thick,  and  hard.  The  contents  of  the  cyst  may  be 
pultaceous  material,  consisting  of  shed  epithelial  scales,  fat, 
and  cholesterin ;  or  laminae  of  firm,  yellowish- white  material, 
arranged  like  the  layers  of  a  bulb.  These  laminae  represent 
the  epithelium  of  the  Hning  wall  that  has  been  shed  in 
successive  layers.  In  rare  instances  the  contents  of  sebaceous 
cysts  calcify.  Sebaceous  cysts  are  sometimes  mistaken 
clinically  for  dermoids,  and  vice  versa. 

Sebaceous  cysts  occur  in  the  "velvet"  covering  the 
growing  antlers  of  deer.  The  velvet  of  a  growing  antler 
is  covered  with  fine  downy  hair  furnished  with  large  seba- 
ceous glands  (Fig.  159). 

Sebaceous    cysts,    apart    from    the    inconvenience    their 


SEBACEOUS   CYSTS  309 

presence  often  causes,  and  their  unsightliness  when  growing 
in  exposed  situations,  become  sources  of  discomfort  when 
their  contents  decompose  or  the  cyst  inflames :  they  are  liable 
to  secondary  changes,  whereby  they  form  peculiarly  foul  and 
f'ungating  ulcers,  or  they  may  develop  horns  {see  Chap, 
XXIII.).     Each  of  these  changes  will  be  considered. 

Decomposition  of  the  contents. — It  has  already  been  men- 
tioned that  the  contents  of  a  sebaceous  cyst  sometimes  ooze 
from  the  orifice  of  the  follicle.  In  some  instances  such  cysts 
give  rise  to  an  extremely  offensive  odour.  This  is  due  to  de- 
composition of  the  cyst-contents  in  consequence  of  admission 
of  air,  and,  as  the  substance  within  the  cyst  contains  a  large 
proportion  of  fat  and  ej)ithelium,  the  odour  evolved  is  not  diffi- 
cult of  explanation.  Decomposition  of  the  cyst-contents  occurs 
independently  of  inflammation  of  the  cyst,  and  is  almost 
confined  to  sebaceous  cysts  occurring  on  the  trunk. 

Inflammation  of  the  cyst. — When  sebaceous  cysts  grow  in 
situations  where  they  are  exposed  to  injury,  as,  for  instance, 
on  the  side  of  the  head,  where  they  may  be  injured  by  the 
hat,  or  on  parts  of  the  body  where  they  are  liable  to  be  rubbed 
by  the  clothes,  they  are  apt  to  inflame  and  suppurate.  An 
inflamed  sebaceous  cyst  has  a  characteristic  colour,  and  re- 
sembles the  deep  red  of  a  ripe  plum.  Such  inflammation  may 
subside  and  recur.  These  recurrent  attacks  of  inflammation 
cause  firm  adhesion  between  the  capsule  of  the  tumour  and 
the  skin,  which  renders  its  removal  somewhat  tedious.  When 
it  suppurates  the  wall  thins,  and  at  last  bursts,  unless  this 
result  is  anticipated  by  the  timely  use  of  a  scalpel.  The  sup- 
puration often  leads  to  its  cure ;  but  fragments  of  capsule  may 
be  retained  and  lead  to  the  formation  of  a  sinus.  In  some 
instances  the  cyst  bursts,  the  pus  escapes,  and  the  point  of 
rupture  heals,  the  cyst- wall  being  retained.  When  this  is  the 
case  the  cvst  refills  with  sebaceous  matter.  Thus,  in  dealino- 
with  these  cysts  surgically,  it  is  an  important  thing  to  remove 
thoroughly  every  particle  of  the  cyst- wall.  Occasionally,  espe- 
cially in  old  persons,  a  sebaceous  cyst  inflam.es,  suppurates, 
and  fungates,  producing  a  foul  offensive  mass  which  is  often 
mistaken  clinically  for  a  cancer  (Fig.  160). 

2.  Sebaceous  adenoma. — It  has  been  so  customary  to 
regard  all  tumours  arising  in  connexion  with  sebaceous  glands 


310 


EPITHELIAL   TUMOURS 


as  wens  or  sebaceous  cysts,  that  it  is  quite  an  exceptional 
event  for  tliem  to  be  submitted  to  microscopical  examination. 
It  has  already  been  pointed  out  that  there  are  two  varieties  of 
sebaceous  cysts,  one  in  which  the  cyst  contains  sebum  and 
epithelial  debris,  and  another  in  which  the  contents  are 
arranged  in  thick  laminae.  In  addition  to  these,  tumours 
occasionally  occur  in  the  skin  and  furnish  the  usual  clinical 
signs  of  wens ;  but  when  removed  and  examined  micro- 
scopically they  are  found  to  be  composed  of  lobules,  which 


Fig.  160. — FuBgating  wen  on  the  scalp  of  a  -woman  83  years  of  age. 

structurally  resemble  the  exuberant  masses  upon  the  nose 
that  used  to  be  called  lipomas,  but  are  now  known  to  be  due 
to  overgrowth  of  the  large  sebaceous  glands  that  occupy  the 
skin  in  this  situation  (Shattock).  These  tumours  are  seba- 
ceous adenomas,  and  they  are  liable  to  ulcerate,  and  excep- 
tionally to  calcify  (Eve). 

Treatment. — A  sebaceous  cyst  is  easily  removed ;  when 
the  skin  covering  one  is  incised  and  the  capsule  exposed,  the 
cyst  usually  shells  out  quite  easily.  When  the  cyst  has  been 
inflamed  and  is  firmly  adherent  to  the  skin,  some  little 
dissection  will  be  necessary  to  effect  its  removal 


RODENT  ULGEB  311 

A  suppurating  cyst  can  in  many  instances  be  dissected 
out.  Often,  however,  the  wall  is  so  thin  that  the  cyst  is  best 
treated  as  an  abscess — that  is  by  free  incision. 

Before  surgeons  appreciated  the  importance  of  extreme 
cleanliness,  the  removal  of  sebaceous  cysts  was  often  followed 
by  septic  inflammation.  An  excellent  notion  of  the  fears 
which  surgeons  entertained  in  regard  to  secondary  compli- 
cations after  the  removal  of  wens  is  furnished  by  the  case  ol 
George  IV.,  who  had  a  sebaceous  cyst  on  the  top  of  his  head. 
This  formed  the  subject  of  a  serious  consultation,  attended  by 
Cline,  Astley  Cooper,  Brodie,  and  others.  Eventually  Cooper, 
with  Cline's  assistance,  removed  the  wen ;  and  his  anxiety  lest 
erysipelas  should  supervene  seems  scarcely  compensated  by 
the  baronetcy  which  the  king  bestowed  upon  him  as  a  reward 
for  the  successful  issue  of  the  operation.  (Life  of  Sir  Astley 
Cooper,  Vol.  ii.,  Chap  ix.) 

Brodie  refers  to  this  case  thus: — •'Eventually  the  operation 
was  performed  by  Sir  Astley  Cooper,  in  the  presence  of  Sir 
Everard  Home,  Mr.  Cline,  Sir  William  Knighton,  the  King's 
physicians.  Sir  Henry  Halford,  Sir  Matthew  Tierney,  and  my- 
self ;  making  a  very  large  assembly  for  so  small  a  matter." 

Cancer  of  sebaceous  glands  (rodent  ulcer). — In  British 
writings  on  Surgery,  it  has  been  customary  for  many  years  to 
describe  under  the  name  of  rodent  ulcer  a  form  of  cancer  • 
which  exhibits  extraordinary  clinical  characters.  In  its 
common  form  a  smooth,  rounded  knob  of  about  the  size  of  a 
split  pea  is  noticed  on  the  skin  of  the  face,  either  on  the  nose, 
eyelids,  orbital  angles,  or  cheek.  This  knob  may  remain  for 
years  (seven,  eight,  or  even  twelve),  and  cause  no  inconveni- 
ence save  unsightliness ;  then  without  obvious  reason  it  may 
ulcerate  and  destroy  the  surrounding  skin  and  underlying 
structures,  involving  all  tissues'in  its  vicinity — skin,  muscles, 
fat,  cartilage,  eyeball,  and  bone — and  producing  horrible  de- 
struction of  the  face,  in  some  cases  even  destroying  the  base  of 
the  skull  and  meninges,  and  exposing  the  brain.  To  produce 
such  terrible  effects  the  disease  requires  sometimes  five,  ten, 
or  even  more  years.  In  its  course  it  destroys  everything, 
never  cicatrizes,  and  is  painless.  This  disease  was  described 
by  Jacobs,  of  Dublin,  in  1827.  It  is  often  called  Jacobs' 
ulcer. 


312  EPITHELIAL   TUMOURS 

In  recent  years  tlae  histology  of  the  early  knohs  which 
mark  the  beginning  of  the  disease  has  been  investigated  with 
great  care.  All  observers  agree  that  the  disease  begins  as  a 
solid  growth  beneath  the  epidermis.  If  in  this  stage  the 
nodule  is  excised  and  sections  are  examined  microscopically, 
it  will  be  seen  to  consist  of  gland -ducts  filled  with  epithelium, 
though  sometimes  they  take  the  form  of  solid  cylinders.  In 
the  later  stages,  when  ulceration  is  in  full  sway,  these  appear- 
ances are  lost. 

The  origin  of  the  initial  knob  has  been  ascribed  to  the 
following  sources :  1,  Sebaceous  glands ;  2,  sweat-glands ; 
3,  the  hair-follicle  ;  4,  the  outer  layer  of  the  root-sheath  of  a 
hair ;  5,  epithelial  remnants  in  the  course  of  the  facial 
fissures ;  6,  vestiges  of  the  tear- pits  of  ruminants ;  and  occa- 
sionally a  hairy  mole.  My  own  investigations  induce  me  to 
ascribe  its  origin  to  the  sebaceous  glands. 

Although  rodent  cancer  arises  mainly  in  the  facial  situa- 
tions already  mentioned,  it  may  occur  on  the  neck  and  the 
pinna  :  it  has  been  met  with  on  the  trunk,  but  never,  so  far  as 
I  know,  on  the  limbs.  It  occurs  most  frequently  in  advanced 
life,  but  is  not  uncommon  between  30  and  50  years.  It  has 
been  recorded  at  the  age  of  20,  but  never  before  puberty 
(fifteenth  year).  It  is  more  frequent  in  men  than  in  women. 
The  extraordinary  features  which  distinguish  it  from  the 
common  kinds  of  cancer  are  the  following:  1,  It  does  not 
infect  lymph-glands  ;  2,  it  does  not  disseminate  ;  3,  though  as 
a  rule  solitary,  it  may  be,  and  often  is,  multiple ;  4,  its  dura- 
tion may  extend  over  many  years. 

Treatment. — When  exposed  to  radium  the  disease  is 
rapidly  arrested,  and  the  ulcer  may  heal  without  leaving 
a  scar. 

Brodie,  Sir  Benjamin,  "Autobiography." 

Eve,  F.  S.,   "  Adenoma  of  the  Sebaceous  Glands  partially  Calcified  "—  Trans. 
Path.  Soc,  xxxiii.  335. 

Shattock,    S.    G.,   "  Sebaceous  Adenoma  of  the  Scal-p."— Trans.    Path.   Soc, 
xxxiii.  290. 

Shattock,  S.  G.,  "  Keratinising  Epithelial  Tumour  from  the  Scalp." — Ibid.,  1897, 
xlviii.  224. 

Thudichum,  J.  L.  W.,  "  The  Demodex  FoUiculorum." — Med.  Press  and  Circular, 
1894,  ii.  103. 


CHAPTER    XXXI 

EPITHELIAL   TUMOURS    OF   THE    THYROID 
GLAND 

Adenoma. — Two  varieties  of  adenoma  are  met  with  in  the 
thyroid  gland ;  by  most  writers  they  are  described  as  adeno- 
matous goitre  and  cystic  goitre  or  bronchocele,  to  distinguish 
them  from  the  general  enlargement  of  the  entire  gland  known 
as  "  parenchymatous  "  goitre.  A  thyroid  adenoma  is  an  en- 
capsuled  tumour  of  the  thyroid  gland  containing  vesicles  of 
the  same  character  as  those  which  make  up  the  normal  gland. 
The  size  of  these  adenomas  varies  greatly ;  many  are  no 
larger  than  cherries,  whilst  others  are  bigger  than  fowls'  eggs. 
When  both  lobes  contain  an  adenoma  the  gland  will  maintain 
its  normal  shape ;  when  one  lobe  only  is  involved,  the  gland 
becomes  unsymmetrical ;  exceptionally,  an  adenoma  will 
develop  in  the  isthmus.  As  the  tumour  increases  in  size  the 
vesicles  coalesce,  the  septa  gradually  disappear,  and  a  thyroid 
cyst  or  bronchocele  is  formed.  Bronchoceles  sometimes  attain 
very  large  dimensions,  and  six  or  more  may  grow  concurrently 
in  the  same  gland.  Their  capsules  are  formed  of  dense  fibrous 
tissue,  which  may  contain  calcareous  plates ;  in  some  old 
specimens  the  capsules  are  converted  into  calcareous  shells. 
Small  bronchoceles  contain  a  thick  peripheral  stratum  of 
glandular  tissue ;  their  central  cavities  contain  colloid  material 
or  a  thinner  fluid  of  a  reddish  colour,  due  to  haemorrhage ;  not 
infrequently  the  fluid  is  largely  charged  with  cholesterin. 
In  very  large  bronchoceles  all  traces  of  gland-tissue  dis- 
appear; nothing  remains  but  a  tough,  more  or  less  calcified, 
cyst- wall. 

Aug.  Reverdin  recorded  a  case  in  which  an  old  man  of 
62  years  had  a  cystic  adenoma  of  the  thyroid  60  cm.  in 
circumference.  On  its  being  punctured  a  large  number  of 
bodies,  white  in  colour  and  crenate  like  mulberries,  escaped, 

313 


314 


EPITHELIAL   TUMOURS 


with  a  large  quantity  of  brown  fluid.  Reverdin  stated  that 
the  composition  of  these  bodies  was  Hke  coagulated  fibrin. 
Bronchoceles  sometimes  attain  great  proportions.  Bruns 
removed  one  which  was  so  large  as  to  reach  as  low  as  the 
navel,  and  its  weight  produced  lordosis  in  the  cervical  and 
kyphosis  in  the  thoracic  regions  of  the  spine  (Fig.  161). 
The  cyst  was   single-chambered  ;    the  walls    were  in  part 


Fig.  161. — Bronchocele  of  unusual  size  in  a  woman  aged  58  years  :  it  was 
successfully  enucleated.     (P.  Bruns.) 

calcified.  The  tumour  was  so  heavy  that  the  woman  was  in 
the  habit  of  resting  it  upon  the  table  when  she  sat  down. 

Mention  must  be  made  of  a  very  rare  form  of  thyroid  cyst 
in  which  the  walls  are  beset  with  papillomas.  Cysts  of  this 
kind  are  apt  to  recur  after  removal  (Barker  and  Pollard). 

Treatment. — Adenomas  of  the  thyroid  gland  and  bron- 
choceles,  when   of  small  size,  rarely  cause   trouble,  and   a 


BR0NGS0CELE8  315 

unilateral  bronchocele  the  size  of  a  closed  fist,  though  it 
appears  unsightly,  is  often  quite  harmless.  Large  broncho- 
celes  sometimes  cause  pain,  and  when  they  press  upon  the 
trachea  give  rise  to  dyspncea,  which  will  in  some  cases  become 
so  alarming  as  actually  to  endanger  life.  There  is  a  very 
rare  variety  known  as  wandering  goitre  on  account  of  its 
mobility.  So  long  as  the  tumour  restricts  its  excursions  to 
the  neck  no  harm  results;  but  occasionally  these  tumours 
will  descend  as  low  as  the  thoracic  inlet.  When  this  happens, 
the  bronchocele  becomes  squeezed  between  the  manubrium 
of  the  sternum  and  the  trachea.  This  impaction  induces 
urgent  symptoms  of  dyspnoea. 

When,  from  unsightliness  or  other  causes,  it  is  deemed 
necessary  to  interfere  with  an  adenoma  of  the  thyroid  or  a 
bronchocele,  it  is  safe  practice  to  enucleate  it.  The  affected 
lobe  is  exposed  through  a  median  or  a  transverse  incision, 
and  the  thyroid  tissue  incised  until  the  capsule  of  the 
tumour  is  exposed.  By  means  of  a  raspatory  the  adenoma 
can  be  shelled  out  of  its  bed  quite  easily.  This  method 
of  treatment  is  quite  as  efficient  as  thyroidectomj^,  and 
the  patient  runs  no  risks  of  haemorrhage,  tetany,  or 
myxoedema. 

The  large  bronchoceles,  although  verj^  unsightly,  are 
not  so  likely  to  lead  to  mischief  as  the  small  bronchoceles 
and  the  more  solid  adenomas  which  compress  the  trachea 
laterally,  causing  this  air-duct  to  assume  the  shape  of  a 
scabbard  (Fig.  3). 

Carcinoma. — The  thyroid  gland  is  liable  to  carcinoma  and 
sarcoma,  but  the  clinical  effects  of  the  two  diseases  are  so  much 
alike  that  it  is  scarcely  possible  to  determine  between  them. 

Cancer  of  the  thyroid  is  an  extremely  rare  condition  in 
England.  Cancer  is  more  liable  to  attack  a  diseased  thyroid 
than  one  which  is  healthy,  and  this  probably  explains  its  fre- 
quency in  goitrous  districts. 

Cancer  of  the  thyroid  usually  occurs  between  the  fortieth 
and  sixtieth  years.  1  had  a  case  under  my  care  in  a  girl 
17  years  of  age;  the  nature  of  the  tumour  was  deter- 
mined by  microscopic  examination  of  portions  of  the  growth 
removed  during  life.  In  its  early  stages  it  resembles  an 
ordinary  goitre,  but  it  steadily  increases  in  size  and  becomes 


316  EPITHELIAL   TUMOURS 

very  hard,  and  afterwards  bossy  oiitgrowtlis  disturb  the  regular 
outline  of  the  gland  :  this  is  always  a  suspicious  sign,  and 
when  it  is  accompanied  by  pain  and  paralysis  of  the  recurrent 
laryngeal  nerve  it  indicates  that  the  adjacent  parts  are  being 
infiltrated ;  this  is  also  indicated  by  the  fixity  of  the  enlarged 
thyroid.  Thrombosis  of  the  thyroid  and  jugular  veins  is 
also  a  valuable  diagnostic  sign  of  cancer  of  the  thyroid 
gland.  In  the  course  of  the  disease  the  internal  jugular  vein 
and  the  carotid  artery  may  be  implicated,  and  even  the 
nerves  of  the  brachial  plexus,  but  the  most  serious  local 
effect  is  due  to  the  disease  involving  the  trachea.  This  is 
a  very  serious  complication,  because  the  implication  of  the 
trachea  not  only  induces  dyspncea,  but  when  the  intruding 
process  ulcerates  it  sets  up  septic  pneumonia,  which  is  usually 
rapidly  fatal.  In  the  early  stages  of  the  disease  the  tumour 
may  so  resemble  an  ordinary  bronchocele  that  the  surgeon 
attempts  to  enucleate  it :  this  happened  to  me  on  one 
occasion,  but  the  free  bleeding  and  indefiniteness  of  the 
tumour  soon  apprised  me  of  the  nature  of  the  case.  The 
patient  recovered  from  the  operation,  but  a  huge  fungating 
mass  slowly  made  its  way  through  the  cicatrix  and  destroyed 
Hfe  in  eight  months.  It  is  a  significant  fact  that  there  is  a 
very  scanty  literature  in  relation  to  the  operative  treatment 
of  malignant  disease  of  the  th3Toid  gland,  which  is  a  clear 
indication  of  its  comparative  rarity  and  the  hopelessness 
of  such  treatment.  There  is  a  feature  of  carcinoma  of 
the  thyroid  gland  which  must  be  referred  to,  and  that  is 
the  infrequency  with  which  it  disseminates.  That  it  occasion- 
ally gives  rise  to  secondary  deposits  is  beyond  dispute, 
and  the  similarity  of  the  structure  of  the  secondary  nodules 
to  the  closed  follicles  of  the  thyroid  has  been  made  the 
subject  of  much  careful  study. 

Parathyroid  bodies. — It  is  highly  probable  that  some 
tumours  supposed  to  arise  in  accessary  thyroids  are  enlarged 
parathyroids.  These  curious  and  important  structures  lie 
in  close  relation  to  the  trachea,  and  even  when  moderately 
enlarged  a  parathyroid  would  compress  this  tube.  (See 
p.  5.) 

General  thyroid  malignancy. — This  term  is  apphed  to  a 
rare  but  very  remarkable  form,  of  disease,  in  which  tumours 


GENERAL   THYROID  MALIGNANCY  317 

structurally  identical  with  the  thyroid  gland  appear  in  the 
bones.  The  fact  which  invests  them  with  more  than  ordinary 
interest  is  that  they  have,  in  nearly  all  instances,  been 
associated  with  an  obvious  enlargement  of  the  thyroid,  which 
clinically  is  indistinguishable  from  the  common  kind  of 
enlargement  known  as  parenchymatous  goitre.  The  earliest 
cases  were  observed  by  Cohnheim  and  Morris. 

Since  1880  a  score  of  cases  have  been  described,  and  from 
the  records  the  following  facts  may  be  stated  :  The  tumours 
occur  most  frequently  in  women  (five  to  one),  and  are  most 
common  between  the  fortieth  and  sixtieth  years,  but  one 
case  has  been  observed  as  early  as  the  twenty-seventh.  They 
show  a  striking  preference  for  the  skull,  but  have  been 
observed  in  the  femur,  clavicle,  sternum,  humerus,  and  on 
several  occasions  in  the  vertebrae. 

In  some  of  the  patients  the  secondary  tumours  are  large, 
and  pulsate.  In  the  extraordinary  case  recorded  by  Cramer 
the  secondary  mass  occupied  the  sternum,  and  pulsated  so 
markedly  and  caused  so  much  pain  that  it  was  mistaken  for 
an  aneurysm:  this  induced  the  surgeon  to  ligature  some  of 
the  large  vessels. 

In  England  the  chief  cases  have  been  observed  and 
recorded  by  Haward,  Coats,  Horsley,  and  Lediard.  Goebel 
has  collected  the  German  literature  in  an  interesting  paper, 
and  has  shown  that  in  many  instances  these  secondary 
tumours  have  been  subjected  to  operative  treatment,  and  on 
the  whole  with  satisfactory  results. 

I  thmk  the  explanation  of  this  interesting  condition  may 
lie  in  the  fact  that  in  the  early  stages  carcinoma  of  the  thy- 
roid is  such  an  insidious  disease,  and  mimics  so  closely  the 
innocent  bronchocele,  that  the  primary  disease  is  overlooked. 
This  view  receives  some  confirmation  from  the  fact  that  a 
very  similar  condition  of  things  is  sometimes  associated  with 
carcinoma  of  the  prostate. 

The  pituitary  body. — The  close  functional  and  structural 
relationship  of  the  glandular  part  of  the  pituitary  to  the 
thyroid  body  makes  it  desirable  to  describe  tumours  of  this 
structure  in  sequence  to  those  of  the  thyroid  gland. 

Adenomas  of  the  pituitary  body  bear  much  the  same 
relation  to  it  that  parenchymatous  goitres  do  to  the  thyroid 


318  EPITHELIAL    TUMOURS 

body;  indeed,  they  are  sometimes  referred  to  as  pituitary 
goitres.  A  few  cases  have  been  observed  in  man.  Goodhart 
described  an  interesting  case  in  a  baboon,  with  its  clinical 
history;    and  Sibley  observed  a  specimen  in  a  ewe. 

These  tumours  are  at  first  isolated  from  the  general  cavity 
of  the  cranium  by  the  circular  fold  of  the  dura  mater  known 
as  the  diaphragma  sellse,  and  they  generally  produce  erosion 
of  the  j^ituitary  fossa. 

Bland-Sutton,  J.,  "  On  a  Tumour  which  probably  arose  in  a  Parathyroid  Body." 
— Arch,  of  Middx.  Hosp.,  1909,  Clinical  Series,  No.  1,  p.  10. 

Bruns,  P.,  "  Cystenkropf  von  ungewohnlicher  Grosse  geheilt  durch  Exstir- 
pation."— ^e(Y.  z.  Mm.  Chir.,  1891,  vii.  650. 

Coats,  J.,  "  A  Case  of  Simple  Diffuse  Goitre,  with  Secondary  Tumour  of  the 
same  structure  in  the  Bones  of  the  Skull." — Trans.  Path.  Soc,  1887, 
xxxviii.  399. 

Cohnheim,  J.,  -  Einfacher  Galtertkropf  mit  Metastasen." — Virchow's  J-rc7i./. 
path.  Anat.,  1876,  Ixviii.  547. 

Cramer,  F.,  "  Beitragzur  Kenntniss  der  Struma  maligna." — Arch.f.  hlin.  Chir. 
(Langenbeck),  1887,  xxxvi.  259. 

Goebel,  C,  "  Ueber  sine  Geschwulst  von  Schilddrusen  artigem  Bau  im  Femur." — 
Deutsche  Zcitschr.f.  Chir.,  1898,  xlvii.  348. 

Goodhart,  J.  F.,  "  Cancer  of  the  Pituitary  Body  in  the  Anubis  Baboon." — Trans. 
Path.  Soc,  1885,  xxxvi.  36. 

Haward,  J.  Warrington,  "Case  of  Bronchocele,  with  Secondary  Growths  in 
Bones  and  Viscera." — Trans.  Path.  Soc,  1882,  xxxiii.  291. 

Horsley,  V.,  "On  the  Rational  Treatment  of  Goitre." — Clin.  Journ.,  1899 
xiii.  321. 

Lediard,  H.  A.,  "  Carcinoma  of  Thyroid  ;  Metastasis  in  Calvaria." — Travis.  Path. 
Soc,  1904,  Iv.  60. 

Loeb,  M.,  and  Arnold,  J.,  "  Adenom  der  Glandula  pituitaria." — Virchow's  J-rcZt. 
f.path.  Anat.,  1873,  Ivii.  172. 

Morris,  H.,  "  Pulsating  Tumour  of  the  Left  Parietal  Bone,  associated  with  other 
similar  Tumours  of  the  Right  Clavicle  and  both  Femora,  and  with  great 
Hypertrophy  of  the  Heart." — Trans.  Path.  Soc,  1880,  xxxi.  259. 

Reverdin,  Aug.,  "  Goitre  Kystique  Uniloculaire  Enorme.  Extirpation  Totale. 
Guerison." — Revue  Med.  de  la  Suisse  Romande,  1883,  xiii.  185  [Observa- 
tion iv.  in  "  Note  sur  vingt-deux  Operations  de  Goitre,"  par  J.  L.  Reverdin 
et  Aug.  Reverdin.] 

Sibley,  W.  K.,  "Abscess  of  Brain  with  Tumour  of  the  Pituitary  Body  and 
Abscesses  in  the  Lungs  in  an  Ewe." — Trans.    Path.  Soc,  1888,  xxxix.  459. 

Wills,  E.,  "Tumour  of  Pituitary  Body  without  Acromegaly." — Brain,  1892, 
XV.  465. 


CHAPTER    XXXII 

CARCINOMA    OF   THE    LIPS,    MOUTH,   TONGUE, 
PHARYNX,    AND    LARYNX 

Cancer  of  the  lips. — In  this  situation  squamous-celled  cancer 
is  common  between  the  thirty-fifth  and  sixtieth  years ;  it  has 
been  recorded  as  early  as  the  twenty-fifth  year  and  as  late 
as  the  hundred-and- third  (Jalland).  A  remarkable  feature 
is  the  preference  it  shows  for  the  lower  lip.  Thus,  out  of 
565  cases  tabulated  by  Loos  in  Bruns'  clinic  at  Tlibingen, 
534  arose  in  the  lower  lip.  Of  these,  467  of  the  patients  were 
men  and  67  women.  It  is  also  remarkable  that  though  men 
are  infinitely  more  liable  to  cancer  of  the  lower  lip  than 
women,  yet  the  liability  is  equal  for  both  sexes  in  regard 
to  the  upper  lip.  Out  of  the  31  cases  of  cancer  in  the  upper 
lip  in  Loos'  total  of  565, 16  occurred  in  men  and  15  in  women. 

The  increased  liability  of  men  to  cancer  of  the  lip  as 
compared  with  women  is  attributed  to  the  greater  frequency 
of  tobacco-smoking  among  men.  In  connexion  with  this 
matter  it  may  be  mentioned  that  cancer  of  the  lip  is  some- 
times spoken  of  as  "  countryman's  cancer,"  on  account  of 
the  frequency  with  which  it  occurs  among  agricultural 
labourers,  who  use  short-stemmed  dirty  pipes.  The  clay 
pipes  with  short  stems  are  very  convenient,  as  they  can  be 
carried  in  the  pocket.  In  London  hospitals  some  patients 
with  cancer  of  the  lip  are  farm-labourers,  but  many  are 
men  who  come  under  the  term  "  labourers,"  and  their  cus- 
tom in  regard  to  the  short  pipe  is  the  same  as  the  farm- 
hand's. The  stem  of  a  short  clay  pipe  soon  becomes  hot 
when  in  use  and  burns  or  scorches  the  lip.  Chronic  ulcers 
caused  by  burns  are  prone  to  be  the  starting-points  of 
squamous-celled  cancers.     (See  p.  256.) 

Women,  too,  who  work  in  the  fields  acquire  the  habit 
of  smoking  short  clay  pipes,  and,  as  far  as  ray  observations 

319 


320  EPITHELIAL  TUMOURS 

go,  in  Germany  more  women  work  in  the  fields  than  in 
England.  This  may  account  for  the  greater  prevalence 
of  cancer  in  the  lip  in  women  of  that  country,  as  shown  in 
the  tables  prepared  by  Loos,  than  we  find  from  an  analysis 
of  the  hospital  lists  of  London. 

Chronic  syphilitic  ulcers  of  the  lips  become  cancerous 
and  account  for  a  certain  number  of  cases  which  occur  in 
non-smokers.  This  is  true  of  the  tongue.  Cancer  is  occa-N 
sionally  seen  in  the  lips  of  patients  who  do  not  smoke 
tobacco,  and  who  are  not  tainted  with  syphilis.  It  is  also 
worth  bearing  in  mind  that  cancer  of  the  lip  is  a  common 
disease  among  those  whom  we  regard  as  the  "  working  class," 
but  this  set  of  men  and  women  do  not  monopolize  tobacco. 
Many  professional  men,  including  the  vicar  of  the  parish, 
smoke  as  hard  as  the  labourer,  yet  it  is  excessively  rare  to 
find  a  case  of  cancer  either  of  the  upper  or  lower  lip  among 
them.  The  preference  of  cancer  for  the  lower  lip  is  not 
easily  explained. 

Cancer  of  the  lip,  when  left  to  run  its  course,  soon  infects 
the  lymph-glands  in  the  submaxillary  region.  Occasionally  it 
will  attack  the  right  side  of  the  lower  lip,  but  infect  the  lymph- 
glands  in  the  left  submaxillary  region,  and  vice  versa.  No 
anatomical  explanation  of  this  anomaly  is  forthcoming.  The 
tissues  of  the  lip  are  gradually  destroyed,  and  the  mucous 
membrane  covering  the  mandible  is  implicated  and  the  bone 
itself  eroded.  In  the  late  stages  the  lymph-glands  in  the  neck 
form  huge  masses,  which  gradually  implicate  the  overlying 
skin,  causing  it  to  ulcerate,  and  at  last  the  ulcer  in  the  neck 
and  the  primary  ulcer  on  the  lip  join;  and  as  the  underlying 
tissues  slough  a  horrible  chasm  is  formed  in  the  neck,  on  the 
floor  of  which  large  vessels  may  be  seen  pulsating.  Death  is 
due  to  asthenia  from  repeated  haemorrhage,  or  from  a  pro- 
fuse hsemorrhage,  septic  pneumonia,  or  oedema  of  the  glottis. 
The  average  duration  of  life  in  untreated  cases  is  twelve 
months. 

Treatment. — Cancer  of  the  lip  in  the  early  stages  is  easily 
removed  by  the  V-shaped  method,  or  some  one  or  other  of 
its  many  modifications.  The  submaxillary  and  submental 
lymph-glands  should  be  dissected  out.  When  the  disease  has 
been  allowed  to  extend  until  it  involves  the  underlying  bone 


GANGER  OF   THE   TONGUE  321 

and  extensively  infiltrates  the  cheek  and  neck,  operative 
interference  can  rarely  be  undertaken  with  good  prospects. 

After  the  excision  of  cancer  of  the  lip,  recurrence  may 
take  place  along  the  edge  of  the  scar,  but  more  frequently  in 
the  cervical  tissues.  There  is  a  form  of  recurrence  which  begins 
near  the  angle  of  the  mandible,  and  spreads  up  each  side  of 
the  body  of  this  bone  in  such  a  way  as  to  resemble  a  peri- 
osteal sarcoma. 

The  early  removal  of  cancer  of  the  lip  is  more  likely  to  be 
followed  by  good  results  than  in  any  other  part  of  the  body. 
Occasionally  the  operation  is  followed  by  quick  recurrence, 
even  when  the  primary  lesion  was  very  small ;  but  in  a 
large  proportion  of  cases  recurrence  is  delayed  two,  three,  or 
more  years,  and  in  a  few  cases  a  cure  is  brought  about. 

Cancer  of  the  tongue. — In  this  situation  cancer  is  most 
frequent  after  the  age  of  40  years,  but  it  has  been  recorded 
in  patients  as  •  young  as  25  and  in  individuals  as  old  as 
75  years ;  it  is  three  times  commoner  in  men  than  in 
women.  The  predilection  of  this  disease  for  the  tongues 
of  men  is  usually  attributed  to  the  habit  of  smoking,  but 
a  very  common  forerunner  of  cancer  of  the  tongue  is  a 
chronic  syphilitic  ulcer.  It  generally  makes  its  appearance 
on  one  side  of  the  tongue,  near  its  tip  ;  in  a  fair  propor- 
tion of  cases  it  starts  on  the  dorsum,  but  always  distinctly 
to  one  side  of  the  middle  line,  and  the  beginning  of  the 
disease  is  always  at  some  spot  in  the  anterior  two-thirds 
of  the  tongue. 

Leukoplakia. — In  a  fair  proportion  of  cases,  cancer  of  the 
tongue  is  preceded  by  chronic  inflammation  of  the  mucous 
membrane  of  the  tongue,  which  leads  to  the  formation  of 
white  patches  of  greatly  thickened  epithelium.  Such  patches 
are  raised  above  the  general  level  of  the  normal  mucosa.  The 
pathological  changes  also  involve  the  subepithelial  tissues- 
This  condition  and  its  relation  to  cancer  of  the  tongue  was  de- 
scribed by  Hulke,  in  1868,  as  ichthyosis  glossse.  This  change 
in  the  lingual  mucous  membrane  is  now  generally  known  as 
leukoplakia,  and  no  one  doubts  that  it  is  a  precancerous 
condition.  At  the  same  time,  it  must  be  borne  in  mind 
that  every  patch  of  leukoplakia  does  not  become  cancerous. 
(Leukoplakia  of  the  vulva  is  also  a  precursor  of  cancer,  p.  369.) 


322  EPITHELIAL    TUMOURS 

When  cancer  attacks  the  tongue  it  usually  destroys  life 
quickly  :  the  lymph-glands  in  the  neck  are  soon  infected, 
and,  as  a  rule,  the  disease  runs  its  course  in  about  a  year. 
The  average  duration  of  life  varies  from  six  to  twenty-four 
months. 

Death  ensues  in  a  large  proportion  of  cases  from  exhaustion 
the  result  of  pain,  distress  of  mind,  and  difficulty  in  taking 
food ;  in  some  it  occurs  from  septic  pneumonia,  the  result  of 
inhaling  the  fetid  discharges  from  the  mouth  ;  a  few  die  early 
from  haemorrhage  when  the  ulceration  opens  up  the  lingual 
or  the  carotid  artery.  Death  is  occasionally  due  to  asphyxia. 
This  may  arise  from  two  causes  :  the  cancer  may  extend  to 
the  base  of  the  tongue  and  infiltrate  the  epiglottis  and  its  folds, 
producing  oedema  of  the  glottis  ;  or  a  mass  of  enlarged  glands 
in  the  neck  may  press  upon  the  trachea  and  cause  suffocation. 

In  addition  to  the  tongue  and  lips,  cancer  may  begin  in 
the  mucous  membrane  of  the  cheek,  in  the  gums,  the  soft 
palate,  tonsils,  and  pharynx. 

In  the  case  of  the  cheek,  cancer  is  sometimes  preceded  by 
a  patch  of  leukoplakia,  as  in  the  case  of  the  tongue.  The 
disease  often  starts  close  to  the  angle  of  the  mouth,  and 
extends  backwards  into  the  cheek ;  or  it  begins  in  the  fold  of 
mucous  membrane  between  the  gum  and  the  cheek ;  and 
occasionally  it  starts  in  the  centre  of  the  cheek,  often  on  a 
level  with  the  meeting-place  of  the  crowns  of  the  upper  and 
lower  molar  teeth. 

Squamous-celled  cancer  may  begin  in  any  part  of  the  gum, 
but  it  appears  more  frequently  in  the  mucous  membrane 
covering  the  lower  than  in  that  covering  the  upper  alveolar 
processes.  The  disease  often  starts  near  the  stwnjp  of  a 
carious  tooth,  and  quickly  infiltrates  the  adjacent  mucous 
membrane ;  thus,  whilst  it  is  eroding  the  bone  it  is  creejjing 
along  the  mucous  membrane  towards  the  cheek  on  one  side 
and  the  tongue  on  the  other.  Similar  effects  may  be  observed 
when  the  disease  attacks  the  gum  in  relation  with  the 
maxilla :  as  the  alveolar  process  is  destroyed  the  cavity  of 
the  antrum  is  exposed,  and  a  foul  ulcerating  chasm  formed. 

One  of  the  facts  connected  with  cancer  of  the  mucosa  of 
the  mouth — and  it  matters  little  whether  the  disease  begins 
on  the  tongue,  cheek,  hard  or  soft   palate,  or  gums — is  the 


BBANGHIOGENOUS   GANGER  323 

extraordinary  size  which  the  infected  lymph-glands  in  the 
neck  sometimes  attain,  whilst  the  ulcer  scarcely  exceeds  1  cm. 
in  diameter.  This  is  worth  bearing  in  mind,  because  an 
enlargement  of  the  cervical  lymph-glands  in  individuals  past 
middle  age  should  always  induce  the  surgeon  to  examine  the 
various  recesses  of  mouth  and  fauces  for  small,  inconspicuous 
cancerous  ulcers,  as  with  every  care  they  sometimes  escape 
detection  during  life.  It  is  necessary  to  emphasize  this, 
because  a  good  deal  has  been  written  about  "  branchiogenous 
cancer,"  or,  as  it  is  sometimes  called,  "  malignant  cyst "  of  the 
neck.  The  tumour,  which  is  most  commonly  observed  after 
the  age  of  50,  is  deeply  seated  in  the  neck,  usually  near  the 
fork  of  the  carotid  ;  it  grows  with  great  rapidity,  and  in  many 
cases  softens  in  the  centre  and  gives  rise  to  fluctuation.  The 
overlying  skin  becomes  brawny  and  red,  and  the  resemblance 
to  an  abscess  is  very  striking.  Gradually  the  implicated  skin 
sloughs,  and  then  a  cancerous  chasm  forms  in  the  neck. 
Some  writers  believe  that  these  are  primary  cancers  arising 
in  remnants  of  branchial  clefts.  My  belief  is  that,  in  most 
of  the  cases,  these  gland-masses  are  secondary  to  cancer 
originating  in  recesses  of  the  pharynx  or  naso-pharynx,  and 
that  the  theory  that  they  arise  in  remnants  of  branchial  clefts 
is  pure  fiction.  A  man  died  in  the  Middlesex  Hospital  (1903) 
Avith  a  malignant  mass  on  the  right  side  of  his  neck,  regarded 
during  life  as  a  branchiogenous  cancer.  At  the  post-mortem 
examination  a  primary  squamous-celled  cancer  was  found  in 
the  external  auditory  meatus.  The  cancer  had  perforated  the 
tegmen  tympani  and  projected  as  a  small  rounded  boss 
which  indented  but  did  not  penetrate  the  temporo-sphen- 
oidal  lobe. 

This  form  of  cancer  runs  a  rapidly  fatal  course :  the  aver- 
age duration  of  life  is  about  six  months ;  it  resents  surgical 
interference,  and  in  the  few  cases  where  patients  have  sur- 
vived operation  quick  recurrence  has  been  the  rule. 

Treatment. — The  results  of  the  operative  treatment  of 
cancer  of  the  tongue  stand  in  striking  contrast  to  those  which 
follow  operations  for  this  disease  when  affecting  the  lower  lip. 

The  manner  of  removing  a  cancerous  tongue  is  modified 
according  to  the  situation  and  extent  of  the  disease.  The 
excision  of  the  anterior  portion  of  the  tongue,  or  the  right  or 


324  EPITHELIAL    TUMOURS 

left  anterior  fourth  of  the  organ  when  the  disease  is  localized 
to  one  side,  is  an  operation  devoid  of  risk  or  difficulty.  When 
the  disease  deeply  invades  the  tongue,  involves  the  floor  of 
the  mouth,  or  extends  so  far  backwards  that,  in  order  to  get 
beyond  the  limits  of  the  disease,  the  surgeon  interferes  with 
the  pillar  of  the  fauces,  then  the  operation  is  often  hazardous. 
The  chief  difficulty  is  connected  with  haemorrhage,  and  in 
order  to  obviate  it  a  variety  of  methods  have  been  advocated 
for  the  excision  of  the  tongue.  A  careful  selection  of  cases, 
wide  removal  of  the  diseased  tissues,  and  extirpation  of  the 
infected  submaxillary  lymph-glands  are  the  points  to  bear  in 
mind. 

It  is  important  in  operating  upon  the  tongue  to  avoid 
the  entrance  of  blood  into  the  trachea,  as  it  is  then  drawn, 
during  inspiration,  into  the  lungs,  and  gives  rise  to  septic 
pneumonia.  Should  blood  in  considerable  quantity  get 
into  the  trachea,  it  may  cause  suffocation.  To  avoid  these 
complications  it  is  useful,  in  extensive  operations  on  the 
tongue,  to  perform  laryngotomy  and  administer  the  anaes- 
thetic through  a  laryngotomy-tube ;  and  in  order  to  prevent 
blood  from  running  into  the  trachea,  the  pharynx  is  plugged 
with  a  sponge. 

The  mortality  of  operations  for  the  removal  of  cancerous 
tongues  is  not  less  than  10  per  cent. ;  the  chief  causes  of 
death  are  hsemorrhage,  septic  pneumonia,  and  asthenia. 

Although  after  excision  of  the  tongue  recurrence  in  the 
stump  or  in  the  neck  within  a  year  of  the  operation 
is  the  rule,  nevertheless  it  is  in  some  cases  delayed  for  five 
and  even  seven  years.  It  is  also  useful  to  bear  in  mind 
that,  in  some  cases  where  the  disease  is  advanced  and  too 
extensive  to  admit  of  removal,  the  pain  may  be  relieved 
by  division  of  the  lingual  nerve  ;  and  a  few  patients  are 
rendered  comfortable  by  ligature  of  the  lingual  and  facial 
arteries. 

It  has  been  mentioned  already  that  cancer  occurring 
in  the  gums  will  afterwards  invade  the  mandible  or  maxilla, 
according  to  its  situation.  Although  in  the  majority  of  in- 
stances in  which  the  maxilla  is  implicated  the  disease  begins 
in  the  gingival  mucous  membrane,  there  is  a  small  number 
of  cases  in  which  patients  past  middle  life  complain  of  pain 


CANCER   OF   THE  LARYNX  325 

in  the  jaw  for  Avhicli  no  adequate  cause  can  be  assigned. 
Gradually  a  slight  fulhiess  is  observed  in  the  infra-orbital 
region,  with  perhaps  oedema  of  the  eyelid,  the  skin  becomes 
brawny,  and  at  last  a  cancerous  ulcer  appears  in  the  skin 
of  the  cheek,  and  the  antrum  is  then  found  to  be  filled 
with  a  tumour.  When  such  a  case  is  submitted  to  opera- 
tion and  the  skin  of  the  cheek  reflected,  the  inroads  the 
disease  has  been  silently  making  on  the  surrounding  parts 
are  seen  to  be  truly  extraordinary.  The  greater  part  of  the 
maxilla  will  be  found  to  be  destroyed,  and  outrunners  from 
the  growth  will  be  seen  in  the  orbit  and  among  the  pterygoid 
muscles.  The  skin  of  the  cheek  is  usually  so  infiltrated 
that  it  must  be  removed.  The  successful  treatment  of 
such  cases  demands  much  boldness  on  the  part  of  the 
operator,  as  he  will  find  it  necessary  to  sacrifice  the  eye 
and  the  orbital  contents,  the  palatine  aspect  of  the  maxilla, 
and  a  portion  of  the  skin  covering  the  cheek :  as  a  result, 
a  large  yawning  cavern  is  left.  Life  is  rarely  prolonged, 
but  the  patients  are  spared  much  pain  and  discomfort. 

Bolam  has  carefully  studied  the  histology  of  primary 
epithelial  tumours  of  the  antrum,  and  has  satisfied  himself 
that  some  of  them  arise  in  the  glands  of  the  antral 
mucous  membrane.  My  independent  examination  of  some 
of  my  own  cases  leads  me  to  take  the  same  view.  Two 
diseases  which  in  their  clinical  course  resemble  and  are 
often  mistaken  for  squamous-celled  cancer  of  the  buccal 
and  nasal  mucous  membrane  are  actinomycosis  and  endo- 
thelioma (Chap.  XLi.). 

Cancer  of  the  larynx. — When  this  disease  originates 
in  the  mucous  membrane  of  the  ventricles,  vocal  cords,  or 
ventricular  bands,  it  is  said  to  be  intrinsic.  When  cancer 
arises  in  the  aryteno-epiglottic  folds,  or  the  mucous  mem- 
brane covering  the  arytenoids  or  the  interarytenoid  folds, 
it  is  said  to  be  extrinsic. 

In  addition,  the  larynx  may  be  implicated  in  carcinoma 
of  the  tongue,  fauces,  or  upper  part  of  the  oesophagus.  Both 
of  these  forms  of  laryngeal  cancer  are  essentially  diseases  of 
adult  life. 

Intrinsic  cancer  of  the  larynx  usually  begins  in  one 
of  the   ventricles,   and   is   almost    invariably    of  the   warty 


326  EPITHELIAL   TUMOURS 

variety :  it  is  particularly  rich  in  cell-nests,  and  these  are 
exceptionally  horny.  The  papillomatous  character  of  intrinsic 
laryngeal  cancer  must  be  borne  in  mind,  or  it  may  lead  to 
grave  errors  in  diagnosis.  The  laryngeal  wart  is  essentially 
a  disease  of  children  and  young  adults,  whereas  carcinoma 
is  an  affection  of  adults,  especially  men  who  have  passed 
the  meridian  of  life.  A  wart-like  growth  in  the  larynx  of 
an  individual  over  40  years  of  life  should  be  viewed  with 
suspicion.  Lymph-gland  infection  and  dissemination  are  not 
marked  features  of  intrinsic  laryngeal  cancer. 

Laryngeal  cancer  is  usually  rapid  in  its  progress;  death 
occurs  in  from  twelve  to  eighteen  months,  and  is  rarely  pro- 
longed beyond  two  years.  The  fatal  result  is  due  to  asthenia, 
which  is  intensified  by  the  difficulty  these  patients  experience 
in  swallowing,  and  pneumonia.  Actual  suffocation  is  obviated 
early  in  the  course  of  the  disease  by  tracheotomy. 

Extrinsic  cancer  of  the  larynx  appea,rs  to  be  a  far  more 
formidable  affection  than  the  intrinsic  form.  It  not  only 
extends  more  rapidly  and  infects  the  lymph-glands  at  a  very 
early  period,  but  implicates  the  surrounding  parts  far  more 
extensively  than  the  intrinsic  variety ;  the  duration  of  life  is 
therefore  shorter.     Dissemination  is  extremely  rare. 

Treatment." — -It  is  of  great  importance  to  recognize  early 
the  nature  of  this  grave  disease  of  the  larynx.  As  a  rule, 
there  is  little  difficulty  in  aj)preciating  the  extrinsic  variety, 
but  the  papillomatous  nature  of  intrinsic  cancer  of  the  larynx 
makes  the  diagnosis  somewhat  dubious  in  the  early  stages. 
Thus  it  is  customary,  when  there  is  an  element  of  doubt 
as  to  the  nature  of  a  laryngeal  growth  in  an  adult,  to  remove 
a  fragment  by  means  of  laryngeal  forceps  and  submit  it  to 
microscopical  examination. 

Acting  on  the  principles  that  prevail  in  the  treatment  of 
cancer  in  other  parts  of  the  body,  surgeons  (following  the 
lead  of  Billroth,  1873)  have  attempted  to  cure  cancer  of  the 
larynx  by  excision.  Unfortunately,  there  is  very  httle  to 
urge  in  favour  of  complete  extirpation  of  the  larynx;  it 
has  been  abandoned  by  most  surgeons  in  the  extrinsic  form 
of  the  disease,  and  even  for  the  intrinsic  form  laryngectomy 
has  fallen  into  disfavour.  The  operation  has  an  excessively 
high    mortality :    a   very   large    proportion    of  the   patients 


GANGER   OF  THE  LARYNX  327 

succumb  to  septic  pneumonia,  and  the  few  tliat  recover  are 
often  in  a  miserable  and  pitiable  condition. 

Excision  of  a  lateral  half  of  the  larynx  for  intrinsic  cancer 
is  a  much  more  successful  operation  ;  and  this  is  also  true  of 
the  operation  known  as  thyrotomy,  in  which  the  thyroid  car- 
tiiaofe  is  di^vided  in  the  median  line  and  the  diseased  sott 
tissues  dissected  out. 

The  reason  that  thyrotomy  is  more  successful  than  laryn- 
gectomy is  found  in  the  fact  that  the  laryngeal  cartilages  are 
not  very  liable  to  be  infiltrated  by  carcinoma.  It  is  therefore 
a  comparatively  simple  operation  to  split  the  thyroid  cartilage 
in  the  middle  line,  thoroughly  expose  the  interior  of  the 
larynx,  and  remove  the  affected  tissues.  In  view  of  the  great 
improvement  in  the  details  of  this  operation,  its  risks  have 
been  reduced  almost  to  a  vanishuig  point.  In  cases  too 
advanced  for  thyrotomy,  the  needs  of  the  patient  are  in 
most  cases  best  satisfied  by  a  simple  tracheotomy. 

For  an  admirable  summary  of  the  operative  treatment  of 
laryngeal  carcinoma,  see  Semon  and  Gluck. 


Bolam,  R.  A.,  "Antral  Carcinoma." — Newcastle-upon-l'i/ne  Journ.  of  FatJi. 
and  Bacterial.,  18U<S,  v.  ()5. 

Gluck  and  Semon,  Sir  Felix,  "  Operative  Treatment  of  Malignant  Disease  of 
the  Larynx."— i^rrt.  Med.  Journ.,  1903,  ii.  1113,  1119. 

Hulke,  J.W.,  "A  Case  of  Extreme  Hypertrophy  of  the  Epithelial  and  Papillary 
Elements  of  the  Mucosa  of  the  Tongue,  Ichthyosis  Glossy,  where,  after 
twenty  years.  Epithelioma  supervened." — Trans.  Clin.  Soc,  1869,  ii.  1. 


CHAPTER  XXXIII 

CARCINOMA  OF  THE  CESOPHAGUS  AND  OF 
THE  GASTRO-INTESTINAL  TRACT 

In  discussing  the  theories  regarding  the  cause  of  cancer, 
attention  has  been  drawn  ah'eady  (p.  280)  to  the  great  frequency 
with  which  the  aUmentary  tract,  and  especially  its  gastro- 
intestinal section,  is  the  seat  of  primary  cancer.  It  is  also  of 
value,  in  studying  the  distribution  of  primary  carcinoma 
among  the  various  sections,  such  as  stomach,  small  intestine, 
large  intestine,  and  rectum,  to  compare  the  regions  vulnerable 
to  this  disease  with  the  favourite  sites  of  intestinal  sarcomas 
(p.  72). 

The  oesophagus. — The  gTillet  is  liable  to  two  varieties  of 
cancer :  that  which  attacks  its  upper  two-thirds  is  squa- 
mous-celled,  whereas  cancer  of  the  lower  segment  is  of  the 
glandular  type.  This  disease  appears  to  be  four  times  more 
frequent  in  men  than  in  women,  and  is  common  between  the 
fortieth  and  sixtieth  years.  It  has  been  observed  as  early 
as  the  thirtieth  year,  and  my  oldest  patient  was  84.  Certain 
parts  of  the  oesophagus  are  more  liable  to  be  attacked  than 
others  :  the  usual  situations  are — 1,  at  the  level  of  the  cricoid 
cartilage  ;  2,  where  it  is  crossed  by  the  left  bronchus ;  3,  at 
its  termination. 

Nothing  is  known  of  the  early  stages  of  cancer  of  the 
oesophagus,  as  it  produces  few  symptoms  until  neighbouring 
structures,  such  as  the  larynx,  trachea,  pleura,  etc.,  are 
implicated. 

The  disease  runs  a  very  rapid  course ;  most  cases  terminate 
fatally  within  a  year  from  the  time  the  patient  comes  under 
observation.  Death  occurs  in  a  variety  of  ways :  inanition 
and  exhaustion  are  the  results  of  obstruction  to  the  passage 
of  food ;  pleurisy  and  septic  pneumonia  are  due  to  perforation 
of  the  pleura  and  trachea.     In  very  rare  instances  an  oesopha- 

328 


GANGER  OF  THE   (ESOPHAGUS 


329 


geal  perforation  into  the  pleura  may  establish  a  well-marked 
pneumothorax.  A  Hstula  between  the  trachea  and  cesophagus 
is  common  in  this  disease.  Mediastinal  abscess,  which  may 
perforate  the  pleura  or  pericardium,  sometimes  forms,  and 
ulceration  has  been  known  to  broach'the  aorta.     When  cancer 


.  Mucous 

iiieiiibraiie. 


Circular 
muscle  layer. 


Longitudinal 
muscle  layer. 


Cancer. 


Diaphragm. 


Fig.  162. — Cancer  of  the  cardiac  orifice  of  the  cesophagus,  from  a  man  aged  48  years. 
The  gullet  has  been  dissected  to  show  the  great  enlargement  of  the  muscular 
layers. 

begins  in  the  cervical  segment  of  the  oesophagus,  the  recurrent 
laryngeal  nerve  is  apt  to  become  entangled;  this  will  cause 
paralysis  of  the  laryngeal  muscles. 

When  the  disease  occupies  the  middle  and  lower  parts  of 


330  EPITHELIAL   TUMOURS 

the  oesophagus,  the  lymph-giancls  of  the  mediastinum  and 
kimbar  region  enlarge.  When  the  upper  third  of  the  tube  is 
imphcated,  the  mediastinal  lymph-glands  and  those  at  the  root 
of  the  neck  are  infected.  The  supraclavicular  lymph-glands, 
or  nodes,  especially  of  the  left  side,  are  often  enlarged  Avhen 
cancer  arises  in  any  part  of  the  gullet  and-  stomach.  This  fact 
is  an  occasional  aid  in  diagnosis  {see  p.  261).  Dissemination 
is  rare. 

When  cancer  attacks  the  oesophagus  where  it  passes 
through  the  diaphragm,  the  tumour  assumes  the  shape  of 
a  spool,  and,  as  the  orifice  becomes  contracted,  the  muscle- 
fibres  of  the  gullet  markedly  hypertrophy  (Fig.  162).  This 
explains  the  great  force  with  which  patients  under  these  con- 
ditions eject  food  and  drink  when  they  attempt  to  swallow. 

Treatment. — Attempts  have  been  made  to  remove  cancer 
of  the  oesophagus  when  it  has  been  situated  high  enough  to' 
be  accessible  in  the  neck.  The  results  are  not  encourascinof. 
When  the  disease  so  obstructs  the  gullet  as  to  render  the 
patient  liable  to  starvation,  gastrostomy  has  been  found  use- 
ful, and  this  is  especially  serviceable  when  the  cancerous 
mass  is  high  in  the  oesophagus,  and  causes  liquids  to  trickle 
into  the  larynx  in  the  act  of  swallowing. 

Efforts  have  been  made  to  treat  cancer  of  the  oesophagus 
with  radium.  The  bronchoscope  has  also  been  of  signal 
service  in  this  disease,  for  it  allows  the  surgeon  to  see  the 
growth  and  obtain  fragments  for  diagnostic  purposes.  When 
the  gullet  is  obstructed  by  cancer,  small  quantities  of  trypsin 
have  beeii  administered  with  the  object  of  causing  digestion 
of  the  growth  and  in  this  way  restoring  a  passage  for  soft 
food.     Remedies  of  this  kind  are  only  palliative. 

The  stomach. — Cancer  of  the  stomach  is  very  common, 
and  stands  third,  as  we  have  seen,  in  the  order  of  frequency 
among  the  organs,  the  mamma  being  first  and  the  uterus 
second  in  order  of  liability.  The  disease  arises  in  the  glands 
which  are  so  abundant  in  the  gastric  nuicous  membrane.  In 
carefulty  prepared  sections  the  epithelium  will  be  found  to  be 
of  the  columnar  variety.  One  of  the  most  striking  features  of 
gastric  cancer  is  the  readiness  with  which  the  cells  undergo 
colloid  change. 

We  have  no  precise  knowledge  of  the  manner  in  which 


OANGEU   OF  THE  STOMACH  331 

the  cancer  begins ;  it  is  commonly  situated  at  or  in  the 
immediate  neighbourhood  of  the  pylorus.  Cancer  arises  at 
the  cardiac  orifice  of  the  stomach  in  about  4  per  cent,  of 
cases.  Occasionally  this  disease  attacks  the  edges  of  chronic 
ulcers,  and  there  is  reason  to  believe  that  it  may  arise  at  the 
edges  of  the  cicatrix  of  a  gastric  ulcer. 

In  the  early  stages  the  disease  is  limited  to  the  mucous 
membrane ;  it  then  invades  the  muscular  and,  in  a  fair  pro- 
portion of  cases,  the  serous  coats.  The  infiltration  of  the 
tissues  about  the  pylorus  leads  to  its  obstruction,  which  is 
often  so  extreme  that  an  ordinary  probe  can  scarcely  traverse 
it.  The  mucous  surface  of  the  tumour  ulcerates,  sloughs,  and 
bleeds.  Occasionally  the  pyloric  branch  of  the  hepatic  artery 
is  eroded,  and  the  bleeding  may  be  so  profuse  as  to  terminate 
life  in  patients  whose  strength  has  been  reduced  by  small 
haemorrhages,  frequently  repeated,  from  the  ulcerating  surface 
of  the  cancer.  Whilst  these  changes  are  in  progress  on  the 
mucous  aspect  of  the  tumour  the  subserous  tissues  become 
infiltrated,  the  overlying  peritoneum  is  involved,  and  ad- 
hesions form  between  it  and  the  omentum,  the  parietal 
peritoneum,  liver,  and  occasionally  the  transverse  colon. 

The  extent  to  which  the  disease  infiltrates  the  surrounding 
parts  varies  greatly.  In  a  large  number  of  cases  it  remains 
restricted  to  a  zone  extendino-  3  cm.  on  each  side  of  the 
pylorus ;  exceptionally  it  will  implicate  the  duodenum  as  low 
as  the  orifice  of  the  common  bile-duct.  More  often  the 
disease  creeps  along  the  lesser  curvature  of  the  stomach. 
When  the  cardiac  orifice  is  attacked,  the  cancer  will  ex- 
tend into  the  oesophagus  and  downwards  along  the  lesser 
curvature. 

For  a  time  the  disease  remains  restricted  to  the  Avails  of 
the  stomach,  but  later  it  spreads  along  the  adhesions  to  such 
structures  as  the  liver,  pancreas,  gall-bladder,  duodenum, 
colon,  spleen,  and  diaphragm  ;  then,  as  ulceration  follows,  it 
happens  that  the  floor  of  the  ulcer  will  be  formed  by  the  liver, 
the  pancreas,  or  the  spleen.  When  such  parts  as  the  colon  or 
duodenum  form  the  base  of  the  ulcer,  perforation  occurs,  and 
a  gastro-colic  or  gastro-duodenal  fistula  is  formed.  These 
fistulse  are  more  common  with  cancerous  than  with  the  simple 
forms  of  gastric  ulcers. 


332  EPITHELIAL    TUMOURS 

The  lymph-glands  in  the  gastro-hepatic  omentum  are 
infected  in  more  than  half  the  cases ;  extensive  enlargement 
of  the  lumbar  glands  sometimes  happens,  and  those  lying 
in  the  posterior  mediastinum  may  be  infected;  the  infec- 
tion sometimes  extends  to  the  glands  at  the  root  of  the 
neck,  and  occasionally  tlie  walls  of  the  thoracic  duct  become 
cancerous  and  its  lumen  obstructed  (Mathieu  Hillier). 
(See  p.  261.) 

Dissemination  is  the  rule  with  cancer  of  the  stomach.  The 
secondary  nodules  usuall}^  make  their  appearance  in  the  liver, 
lungs,  and  frequently  in  one  or  both  ovaries  (Chap.  Li.). 

The  walls  of  the  stomach  are  occasionally  so  infiltrated 
with  cancer  that  the  organ  becomes  quite  firm  and  assumes 
the  shape  of  a  leather  bottle.  When  the  peritoneal  surface 
of  the  colon  is  implicated,  this  portion  of  the  intestine  assumes 
a  rigid  leathery  condition.  (Nuthall  and  Emanuel  have 
recorded  some  examjDles.) 

There  is  a  curious  and  somewhat  rare  condition  of  the 
omentum  associated  w^ith  cancer  of  the  stomach.  That  it  is 
little  understood  may  be  inferred  from  the  variety  of  names 
applied  to  it — colloid  or  hydatid  tumour ;  colloid  cancer ; 
myxo-sarcoma  of  the  omentum.  There  can  be  little  doubt 
that  the  uncertainty  of  knowledge  concerning  it  is  very  largely 
due  to  its  rarity.  In  typical  cases  the  omentum  is  greatly 
thickened  (5  to  10  cm.),  and  it  may  weigh  upwards  of  ten 
pounds.  The  surface  is  flocculent,  and  on  close  inspection 
small  rounded  collections  of  gelatinous  material  may  be  seen 
in  the  midst  of  the  villous  processes  ;  some  of  them  are 
stalked  and  look  like  white  currants.  On  microscopic  exam- 
ination the  bulk  of  the  omentum  is  found  to  be  made  up 
of  myxomatous  tissue ;  but  here  and  there  are  collections  of 
epithelial  cells  surrounded  by  incomplete  capsules  of  fibrous 
tissue.  The  condition  is  due  to  infiltration  of  the  great 
omentum  from  a  cancerous  stomach,  and  the  cancerous 
material  with  the  proper  omental  tissue  undergoes  colloid  or 
myxomatous  degeneration.  The  subject  requires  the  close 
investigation  of  perfectly  fresh  material  for  its  proper  elu- 
cidation. Attention  has  already  been  drawn  to  the  ex- 
treme liability  of  cancer  of  the  stomach  to  undergo  colloid 
degeneration. 


CANCER    OF  TEE   STOMACH  333 

Clinical  features. — Cancer  of  the  stomach  is  rare  hefore 
the  thirtieth  year ;  it  is  most  common  between  the  fortieth 
and  sixtieth  years  ;  it  has  been  demonstrated  as  early  as  13, 
near  the  cardiac  end  of  the  viscus,  in  a  girl  (Norman  Moore), 
and  in  a  boy  aged  14 1  (Ness  and  Teacher). 

Gastric  carcinoma  runs  a  very  rapid  course,  life  being 
rarely  prolonged  beyond  twelve  months  from  the  time  the 
disease  is  first  recognized.  Its  rapidly  fatal  course,  especially 
when  the  pylorus  is  implicated,  is  largely  due  to  the  obstruc- 
tion offered  to  the  escape  of  food  into  the  duodenum  ;  hence 
the  food  is  retained  in  the  stomach,  which  often  becomes 
dilated  into  a  huge  sac,  sometimes  reaching  as  low  as  the 
pubes.  The  retained  and  partially  digested  food  ferments, 
and  the  contents  of  the  stomach  are  vomited  at  irreo-ular 
intervals,  mixed  with  altered  blood  which  escapes  from  the 
ulcerated  surface  of  the  tumour. 

When  cancer  involves  the  cardiac  orifice,  the  stomach  is 
usually  contracted.  Cancer  of  the  stomach  causes  death  in 
various  ways.  Of  these  the  chief  are — exhaustion  duo  to 
starvation  and  frequent  hsemorrhage ;  perforation  into  the 
general  peritoneal  cavity  and  fatal  peritonitis.  In  exceptional 
instances  the  diaphragm  is  perforated  and  fatal  pleurisy 
ensues. 

An  imj)ortant  feature  of  gastro-intestinal  cancer  is  its 
proneness  to  permeate  the  musculo-serous  walls  of  the 
stomach  or  the  colon.  In  this  event  the  cancer-cells  find 
their  way  into  the  general  peritoneal  cavity  and  settle  on  the 
ovaries,  tubes,  and  uterus.  Vagrant  cells  of  this  kind  give 
rise  to  large  masses  in  the  ovary,  frequently  regarded  as 
primary  ovarian  tumours,  and  are  often  removed  under  this 
impression,  the  primary  disease  in  the  stomach  or  gut  being 
overlooked,     (See  Chap.  Li.) 

Treatment. — The  only  radical  method  for  the  relief  of 
gastric  cancer  is  wide  excision.  When  the  disease  attacks  the 
pylorus,  this  part  is  excised,  and  the  cut  edges  of  the  stomach 
and  duodenum  (pylorectomy)  are  carefully  sutured.  When 
this  is  impracticable  on  account  of  the  wide  extent  of  the 
disease,  or  lymph-gland  infection  and  dissemination,  then,  in 
order  to  obviate  inevitable  death  by  starvation,  a  fistula  may 
be  established  between  the   stomach  and  jejunum   (gastro- 


334  EPITHELIAL    TUMOURS 

jejunostomy),  a  proceeding  which  has  occasionally  been 
followed  by  a  small  amount  of  success ;  but  it  is  merely  a 
palliative  procedure. 

Encouraged  by  the  occasional  success  of  pylorectomy, 
surgeons  have  extended  their  efforts,  and  in  1897  Schlatter 
removed  the  entire  stomach  from  a  woman  aged  56,  for  car- 
cinoma. The  patient  survived  the  operation  fourteen  months, 
and  died  with  local  recurrence  or  dissemination. 

The  results  of  the  operative  treatment  of  gastric  carcinoma 
have  been  ably  summarized  by  Herbert  J.  Paterson,  in  his 
Hunterian  Lectures  on  Gastric  Surgery,  1906  ;  he  has  col- 
lected seventeen  cases  in  Avhich  total  removal  of  the  stomach 
(gastrectomy)  has  been  followed  by  success,  six  of  the  patients 
being  alive  three  years,  and  three  of  them  five  years,  after 
the  operation.  Paterson  also  emphatically  points  out  that  the 
more  radicall}^  cancer  of  the  stomach  is  treated  by  operation, 
the  better  are  the  remote  results  for  the  patients;  in  this 
respect  the  surgery  of  gastric  carcinoma  harmonizes  with  the 
results  of  thorough  operations  in  the  treatment  of  mammary 
cancer.  He  also  points  out  that  after  the  removal  of  the 
stomach,  its  functions  are  vicariously  performed  by  other 
parts  of  the  alimentary  canal.  For  example,  its  function  as 
a  reservoir  is  supplied  to  a  limited  extent  by  dilatation  of  the 
lower  end  of  the  cesophagus ;  maceration  of  the  food  is 
replaced  by  careful  dieting;  the  chemical  functions,  the 
secretion  of  pepsin,  hydrochloric  acid,  and  rennin,  can  be 
effectively  replaced  by  the  intestine.  The  function  of  rennin 
can  be  performed  by  pancreatic  juice;  the  antiseptic  action 
of  the  hydrochloric  acid  is  carried  on  by  the  bile ;  and  the 
peptones  are  absorbed  by  the  small  intestine. 

The  rectum. — Carcinoma  of  the  rectum  becomes  clinically 
recognizable  as  a  hard  tuberous  mass  in  the  mucous  mem- 
brane, which  slowly  spreads  at  its  periphery  and  gradually 
travels  round  the  bowel  and  forms  a  thick  circular  diaphragm 
with  a  central  perforation  no  wider  than  a  crow-quill.  In 
some  specimens  the  lumen  of  the  bowel  is  narrowed  not  so 
much  by  the  exuberance  of  the  growth  as  by  the  contraction 
it  exercises  upon  the  intestinal  wall.  Sometimes  the  tumour 
will  have  a  diameter  of  2  cm.  and  less,  yet  its  power  of  con- 
traction is  so  great  that  it  completely  obstructs  the  bowel. 


GANGER   OF   THE   BEGTUM 


335 


This  variety   is   more    frequent    in  the   colon   than   in   the 
rectum. 

In  some  cases  the  disease,  instead  of  forminof  a  localized 
tuber,  tends  from  tbe  first  to  infiltrate  the  muscular  as  well 
as  the  submucous  tissues  (Fig.  163),  and  even  extends  beyond 
the  confines  of  the  gut  to  adjacent  parts,  such  as  the  perito- 
neum, pelvic  connective  tissue,  prostate,  or  vagina.    Ulceration 


Fig.  163. — Side  view  of  the  male  pelvis  in  an  advanced  case  of  rectal  cancer,  to  show 
its  infiltrating  tendency. 

occurs  early  in  this  variety.  Whilst  in  one  case  the  cancer 
tends  to  penetrate  the  wall  of  the  rectum,  in  another  it  will 
form  large  and  exuberant  masses,  blocking  up  the  gut  and 
even  protruding  beyond  the  anus.  It  may  in  a  third  case 
be  restricted  to  a  narrow  area  of  the  bowel,  and  remain 
apparently  indolent  for  a  long  period. 

Rectal  carcinoma  consists  of  glandular  recesses,  lined  with 
tall  colamnar  cells,  embedded  in  a  stroma  of  dense  connective 


336  EPITHELIAL    TUMOURS 

tissue.  In  order  to  make  out  the  nature  of  the  growth, 
sections  should  be  taken  from  the  margins  of  the  tumour, 
because  the  deeper  parts  are  much  altered  by  ulcerative  and 
necrotic  changes.  As  a  matter  of  fact,  in  many  cases  of 
rectal  cancer,  judging  merely  from  the  appearances  under 
the  microscope,  it  would  be  difficult  to  determine  whether  a 
section  was  prepared  from  an  adenoma  or  a  carcinoma ;  but 
it  must  be  borne  in  mind  that  the  adenoma  remains  restricted 
to  the  mucous  membrane,  whereas  in  cancer  we  find  the 
glands  with  their  characteristic  columnar  cells  interspersed 
among  the  muscular  fasciculi  of  the  gut-wall.  The  propor- 
tion of  connective  tissue  varies  greatly.  In  some  cancers  the 
glands  are  closely  set ;  in  others  they  are  ill-formed,  arranged 
irregularly,  and  embedded  in  an  abundance  of  connective 
tissue.  Occasionally  collections  of  Ij^mphoid  tissue  are  ob- 
served. When  a  rectal  cancer  invades  the  anus,  the  part  of 
the  tumour  which  involves  the  anus  loses  its  glandular 
character  and  assumes  the  squamous-celled  form  (Harrison 
Cripps).  Rectal  cancer  is  very  rare  before  the  age  of  20  ; 
it  is  common  in  men  and  women  between  the  thirtieth  and 
fifty-fifth  years. 

The  pelvic  and  lumbar  lymph-glands  are  first  involved, 
then  those  glands  lying  in  the  course  of  the  external  iliac 
artery.  Should  the  skin  of  the  anus  become  infiltrated,  then 
the  inguinal  lymph-glands  may  be  infected.  The  liver  is  the 
seat  of  secondary  deposits  in  a  large  proportion  of  cases  of 
rectal  cancer.  Occasionally  widespread  dissemination  occurs, 
and  nodules  are  formed  not  only  in  the  liver,  but  in  the 
lungs,  kidneys,  and  bones.  Few  things  are  more  surprising 
than,  on  examining  a  cancer-nodule  from  the  liver,  or  from  a 
long  bone  like  the  humerus,  to  find  Lieberklihn's  glands  with 
their  tall  columnar  epithelium. 

When  rectal  cancer  invades  the  peritoneum,  this  serous 
membrane  will  sometimes  become  dotted  over  with  minute 
elevations  like  sago  grains. 

The  intestine. — Cancer  of  the  small  and  the  large  intestine 
is  of  the  same  structure  and  has  the  same  relation  to  the  gut 
as  that  which  occurs  in  the  rectum.  The  liability  of  the 
various  sections  of  the  intestine  to  cancer  varies  greatl}^  In 
the  duodenum,  jejunum,  and  ileum  this  disease  is  very  rare. 


GANGER   OF   THE  ILEO-G^GAL    VALVE 


537 


When  cancer  attacks  the  duodenum  it  is  apt  to  involve  the 
common  bile-duct ;  in  a  fair  proportion  of  cases  it  begins 
around  the  bile-papilla.  In  the  large  bowel,  excluding  the 
rectum,  cancer  is  fairly  frequent,  and  exhibits  a  curious 
tendency  to  occur  at  the  sigmoid,  splenic,  and  hepatic 
flexures  (Fig.  164). 

A  search  through  the  home  literature  indicates  that  few 
records  of  cancer  of  the  ileo-csecal  valve  exist,  especially  if 
care  be  taken  to  distinguish  between  cancer  of  the  csecum 


Fig.  164. — Cancer  of  the  sigmoid  flexure  of  the  colon. 

involving  this  valve,  and  primary  cancer  of  the  valve  itself. 
In  one  remarkable  case,  cancer  of  the  ileo-ccecal  valve  caused 
intussusception,  and  the  valve  appeared  at  the  anus.  The 
cancerous  valve  was  cut  away,  and  the  vermiform  appendix, 
recognized  as  the  peritoneum,  was  opened.  The  patient,  a 
woman  of  75  years,  died  suddenly  ten  hours  later  (Ball). 

Cancer  is  less  common  in  the  ca?cum  than  in  other  parts 
of  the  colon.  Cellulitis  involving  the  cfficum  is  often  mis- 
taken for  cancer  of  this  part  of  the  large  bowel. 

The  vermiform  appendix.— Though  primary  cancer  of  this 
w 


338 


EPITHELIAL    TUMOURS 


small  portion  of  the  alimentary  canal  lias  been  recorded  by 
many  observers,  the  analysis  of  a  number  of  reported  cases 
collected  by  RoUeston  shows  that  the  disease  described  as 
cancer  of  the  vermiform  appendix  differs  in  a  very  striking 
manner  from   cancer  in  other  parts  of  the   intestine   in   its 


Fig.  165. — Cancer  of  colou  (coustrictiug  variety).      lu  this  variety  the  cancer 
is  undergoing  spontaneous  cure. 

slight  degree  of  malignancy.  He  considers  a  case  re- 
ported byBerger  in  1882  to  be  the  first  incontestable  example 
of  cancer  of  the  vermiform  appendix.  In  some  of  the  cases 
the  diseased  area  was  so  small  as  to  require  a  magnifying 
glass  to  see  it.  The  cancer  is  spheroidal-celled;  and  the 
immediate  prognosis  as  well  as  the  ireedom  from  recurrence 
after  operation  is  extremely  good.  Some  of  the  examples  of 
primary  malignant  disease  of  the  appendix  have  been  de- 
scribed as  sarcomas  and  as  endotheliomas. 


GANGER   OF  THE  INTESTINE  339 

Clinical  characters  of  carcinoma  of  the  small  and  the 
large  intestine.  —  The  symptoms  to  which  cancer  of  the 
intestine  gives  rise  are  those  of  obstruction,  and  diagnosis 
is,  in  most  cases,  a  matter  of  conjecture,  mainly  based  upon 
the  age  of  the  patient  and  the  gradual  manner  in  which  the 
signs  develop,  leading  the  surgeon  to  the  conclusion  that  the 
trouble  is  due  to  cancer  in  some  part  of  the  large  intestine. 
As  far  as  I  am  aware,  the  diagnosis  of  primary  cancer  of  the 
small  intestine  has  not  been  made,  for,  when  seated  in  the 
small  gut  below  the  duodenum,  cancer  usually  gives  rise  to  signs 
of  acute  obstruction.  From  this  it  follows  that  our  knowledge 
of  intestinal  cancer  is  based  upon  a  study  of  the  disease  in  its 
advanced  stage.  One  of  its  most  characteristic  features  is  the 
way  it  travels  round  the  gut  and  forms  a  zone  of  hard 
material  projecting  into  its  lumen,  and  then,  as  it  contracts, 
the  diseased  parts,  as  seen  from  the  outside,  look  as  if  the 
intestine  had  been  girt  with  a  ligature  (Fig.  165).  In  the  later 
stages  the  lumen  of  the  gut  becomes  so  straitened  that 
nothing  but  a  narrow,  tortuous  channel  traverses  the  cancerous 
mass.  This  allows  the  liquid  faeces  retained  in  the  dilated 
segment  of  the  gut  on  the  proximal  side  of  the  tumour 
gradually  to  trickle  through,  but  at  times  even  this  limited 
channel  of  escape  becomes  closed.  Occasionally,  after  many 
daj^s  of  complete  obstruction,  a  portion  of  the  cancer  sloughs, 
and  the  obstruction  is  temporarily  relieved.  The  enormous 
quantity  of  fteces  that  sometimes  escapes  on  such  occasions  is 
almost  beyond  belief. 

The  constricting  variety  of  cancer  in  the  colon  is,  like 
atrophic  cancer  in  the  breast,  an  example  of  the  disease 
undergoing  spontaneous  cure.  Occasionally  the  hard  ring 
resulting  from  the  contraction  of  the  cancer  acts  as  a  polypus 
will,  and  produces  intussusception.  I  have  operated  on  such 
a  case. 

The  chief  difficulty  with  which  surgeons  have  to  contend 
in  the  diagnosis  of  cancer  of  the  gastro-intestinal  tract  is  the 
absence  of  specific  symptoms.  When  a  lump  in  the  stomach 
or  intestine  is  exposed  in  the  course  of  an  operation,  eyes  and 
fingers  are  often  incompetent  to  decide  for  or  against  malig- 
nancy. The  condition  of  the  big  bowel  known  as  hyperplastic 
tuberculous  disease,  in  its  naked-eye  characters  and  effects  on 


Fig.  166.— Csecum  with  the  Yemiiform  aj)pendix  and  adjaceut  segments  of  the 
ascending  colon  and  ileum.  The  CEecum  is  occupied  with  a  cancerous  mass, 
which  has  perforated  its  mesial  wall,  and  not  only  implicated  the  adjacent  seg- 
ment of  the  ileum  but  has  penetrated  its  lumen.  The  parts  were  successfully 
resected  from  a  woman  set.  55.  She  was  alive  and  in  good  health  four  years 
after  the  ojieratiou, 

340 


CANGEB   OF   THE   COLOR  341 

the  gut  simulates  cancer  very  strongly.  On  microscopic 
examination,  however,  the  presence  of  giant-cell  systems 
affords  an  unerring  means  of  distinction.  Inflammatory 
thickenings  around  the  ctecum  often  cause  great  difficulty 
in  diagnosis. 

A  large  proportion  of  patients  with  intestinal  cancer 
succumb  from  the  effects  of  obstruction ;  in  some  death  is 
brought  about  by  other  means.  For  example,  the  retention 
of  the  contents  of  the  bowel  leads  to  dilatation  of  the  gut 
above  the  stricture  ;  this  may  induce  ulceration  and  gangrene, 
which  terminate  in  perforation.  In  this  event  the  effect 
depends  on  the  part  of  the  gut  perforated.  Should  the 
opening  allow  ftecal  matter  to  escape  into  the  peritoneal  cavity, 
peritonitis  is  the  consequence,  and  as  a  rule  kills  the  patient 
in  a  few  hours.  In  the  case  of  the  ciecum,  the  ascending  and 
descending  colon,  the  extravasation  may  take  place  behind 
the  peritoneum  and  give  rise  to  a  fsecal  abscess.  Such 
abscesses  in  connexion  with  the  right  colon  will  point  in  the 
neighbourhood  of  Poupart's  ligament  (usually  above,  but 
sometimes  below  this  band),  or  at  the  crest  of  the  ilium.  1 
have  known  pus  from  an  abscess  of  this  kind  in  connexion 
with  the  descending  colon  to  travel  between  the  muscular 
planes  of  the  belly-wall  as  far  as  the  linea  semilunaris,  and 
the  intestinal  gas  caused  the  Avhole  of  the  left  half  of  the 
belly-wall  to  be  emphysematous. 

In  chronic  intestinal  obstruction  due  to  cancer  of  the 
descending  colon,  the  caecum  becomes  greatly  distended  w^ith 
fluid  fseces ;  this  leads  to  ulceration  of  its  wall,  which  some- 
times perforates  and  sets  up  rapidly  fatal  peritonitis. 

It  occasionally  happens  that  a  distended  coil  of  bowel 
immediately  above  a  cancerous  stricture  will  adhere  to  an 
adjacent  piece  of  healthy  intestine,  which  will  be  infiltrated 
by  the  cancer ;  sloughing  follows,  and  a  fistula  forms  between 
the  implicated  coils.  Such  an  event  rarely  improves  the 
patient's  condition,  as  the  communication  almost  always  takes 
place  with  a  piece  of  intestine  on  the  proximal  side  of  the 
stricture.  It  has  happened  to  me  on  three  occasions  to  meet 
with  cancer  in  the  loop  of  an  omega-shaped  transverse  colon. 
The  cancerous  portion  had  in  two  instances  come  in  con- 
tact with,  and  perforated  into,  the  bladder.     Uterine  cancer 


342  EPITHELIAL   TUMOURS 

sometimes  perforates  into  the  peritoneal  cavity  and  implicates 
the  colon ;  hence  care  is  necessary  in  discriminating  between 
a  cancerous  colon  adherent  to  the  uterus  and  a  cancerous 
uterus  implicating  the  colon.  Cancer  of  the  sigmoid  flexure 
is,  in  a  large  proportion  of  cases,  localized  in  that  portion  of 
the  flexure  in  relation  with  the  brim  of  the  true  pelvis ;  and  it 
is  a  curious  fact  that  in  such  cases  the  left  ovary  is  often 
adherent  to,  and  occasionally  forms  the  base  of,  a  cancerous 
ulcer  in  this  part  of  the  colon. 

Briefly  summarized,  the  modes  of  death  in  cancer  of  the 
intestines  are :  Intestinal  obstruction,  intussusception,  per- 
foration into  the  peritoneal  cavity,  and  suppurative  nephritis 
when  the  disease  is  in  the  rectum  and  involves  the  ureters ; 
also  the  complications  which  ensue  from  the  general  dissemi- 
nation of  the  disease. 

Treatment.— Cancer  of  the  Tectum  can  in  many  instances 
be  easily  and  freely  excised  (proctotomy).  A  ready  way  in 
which  surgeons  estimate  the  suitability  of  a  rectal  cancer  for 
excision  is  to  introduce  the  index  finger  through  the  anus,  and 
if  the  tip  of  the  finger  passes  beyond  the  tumour  it  is  taken  as 
an  indication  that,  so  far  as  implication  of  the  rectum  is  con- 
cerned, the  disease  admits  of  removal.  The  favourable  cases 
are  those  in  which  the  cancer  is  mainly  limited  to  the 
posterior  wall  of  the  gut,  and  does  not  involve  the  anus, 
prostate  or  vagina,  according  to  the  sex.  When  rectal  cancer 
is  too  extensive  for  excision,  patients  are  often  rendered 
comfortable  by  inguinal  or  lumbar  colotomy.  The  routine 
employment  of  colotomy  for  every  case  of  rectal  cancer  that 
cannot  be  excised  is  to  be  deprecated. 

In  the  case  of  the  colon  various  methods  have  been  ad- 
vocated. The  ideal  operation  consists  in  resection  of  the 
diseased  area  of  the  gut  and  sutural  union  of  the  cut  ends  so 
as  to  restore  the  continuity  of  the  intestine. 

In  all  patients  who  come  under  my  care  with  intestinal 
obstruction  supposed  to  depend  upon  cancer  of  the  colon,  and 
in  whom  no  tumour  can  be  localized  by  physical  signs,  I  prefer 
to  explore  the  intestines  through  an  abdominal  incision,  and 
then  perform  colotomy  or  resection,  according  to  the  nature 
and  situation  of  the  cancer.  In  cases  where  the  cancer  is 
situated  in  the  laro^e  bowel  well   above  the  rectum  and  too 


GANGER   OF  THE  ANUS  343 

extensive  to  permit  removal,  the  patient  may  be  spared  tlie 
misery  of  colotomy,  for  the  ileum  may  be  turned  into  the 
large  gut  below  the  obstruction  (ileo-colostomy).  In  appro- 
priate cases  this  is  an  excellent  operation. 

It  is  also  a  fact  well  worth  bearing  in  mind  that  when  the 
pressure  upon  a  section  of  colon,  straitened  by  cancer,  is  re- 
lieved by  a  timely  colotomy,  the  obstruction  after  a  time 
partially  disappears  and  allows  f^ces  once  more  to  pass  into 
the  distal  portion  of  the  gut.  Indeed,  in  some  cases  the 
passage  through  the  cancerous  segment  becomes  so  free  that 
patients  allow  the  colotomy  opening  to  close. 

The  various  methods  of  performing  resection  of  the  bowel, 
and  the  results,  immediate  and  remote,  are  discussed  in  many 
admirable  works  on  Operative  Surgery  now  available. 

The  anus. — Cancer  of  the  anus  is  of  the  squamous- 
celled  variety,  and  is  about  equal  in  frequency  to  this  disease 
in  the  scrotum  and  labia.  It  is  more  frequent  in  women  than 
in  men,  and  rarely  begins  before  the  fortieth  year.  In  about 
half  the  cases  the  inguinal  glands  are  affected  on  one  or  both 
sides.  When  seen  in  the  early  stages  and  its  nature  recognized, 
cancer  of  the  anus  admits  of  free  and  complete  removal ; 
care  should  be  taken  to  remove  the  inguinal  lymph-glands 
either  at  the  primary  operation  or,  better,  two  or  three  weeks 
later.  The  results  of  such  interference  are  admirable.  In 
cases  where  the  disease  runs  its  course,  life  is  rarely  prolonged 
beyond  twelve  months ;  whereas,  in  cases  where  the  growth  is 
satisfactorily  removed,  life  has  been  prolonged  several  years 
(five  to  eight).  When  the  disease  cannot  be  extirpated,  the 
patients  are  sometimes  made  more  comfortable  by  diverting 
the  course  of  the  feeces  (colotomy). 

As  a  rule,  cancer  of  the  big  bowel,  when  it  has  progressed 
to  the  staofe  at  which  it  causes  intestinal  obstruction  and 
demands  colotomy,  destroys  life  in  eighteen  months;  oc- 
casionally patients  survive  colotomy  for  undoubted  cancer 
of  the  colon,  five  and  even  seven  years.  This  is  a  matter  of 
importance,  for  it  shows  that,  when  cancer  attacks  the  bowel, 
if  the  gross  mechanical  effects  be  overcome  this  disease 
may  pursue  a  chronic  course.  Kadium  has  been  found  of 
temporary  benefit  in  local  recurrence  after  excision  of  the 
lower  end  of  the  rectum  for  cancer. 


344  EPITHELIAL    TUMOURS 

Ball,  Sir  Charles,  "  On  Adeno- Carcinoma  of  the  Stomach." — Brit.  Med.  Journ., 
1903,  i.  481. 

Keyser,  C.  R.,  "  A  Case  of  Carcinoma  of  the  Jejunum,  -with  remarks  on  Malig- 
nant Disease  of  the  Small  Inte&tme."— Lancet,  1908,  ii.  304. 

Moore,  Norman,   Trans.  Path.  Soc,  xxxvi.  195. 

Ness,  R.  B.,  and  Teacher,  J.  H.,  "A  Case  of  Carcinoma  of  the  Stomach  in  a  Boy 
aged  fourteen  years  and  nine  months." — Brit.  Journ  Child.  Bis.,  1908, 
V.  515. 

Nuthall,  A.  W.,  and  Emanuel,  J.  G.,  "  Diffuse  Carcinomatosis  of  the  Stomach 
and  Intestines." — Trans.  Path.  Soc,  liv.  90. 

Paterson,  Herbert  J.,  "  Lectures  on  Gastric  Surgery." — Lancet,  1906, 
i.  491,  574. 

RoUeston,  H.  D.,  and  Jones,  La-wrence,  "  Primary  Malignant  Disease  of  the 
Vermiforni  Appendix." — Med.-Chir.  Trans.,  1906,  Ixxxix. 

Schlatter,  "(Esophago-Enterostomy  after  Total  Extirpation  of  the  Stomach." — 
Lancet,  1898,  i.  141. 


CHAPTER  XXXIV 

EPITHELIAL    TUMOURS    OF    THE    LIVER,    GALL- 
BLADDER,  AND    PANCREAS 

THE   LIVER 

The  liistological  cliaracters  of  the  liver  render  it  possible  for 
epithelial  tumours,  whether  adenonia  or  carcinoma,  to  imitate 
the  tubular  arrangement  of  the  bile-ducts,  or  the  disposition 
of  cells  characteristic  of  a  hepatic  lobule. 

Adenoma. — Fully  developed   adenomas   of  the  liver   are 


Fig.  167- — Adenoma  of  the  liver.     {After  Paid.) 
a,  Section  of  blind  duct  filled  with  green  fluid  ;  b,  Hver-ceUs ;  c,  connective  tissue. 

encapsuled  tumours  of  a  spherical  shape;  they  may  be 
situated  in  any  part  of  the  liver.  Hepatic  adenomas  vary 
greatly  in  size :  a  sohtary  adenoma  may  be  no  larger  than  a 
marble;  when  multiple  they  will  be  as  big  as  Tangerine 
oranges.  In  colour  some  are  bright-green,  others  are  dull- 
white.  The  peripheral  parts  of  the  tumour  consist  of  solid 
columns  of  cells,  but  on  approaching  the  centre  they  gradually 

34.5 


346  EPITHELIAL    TUMOUBS 

acquire  a  lumen  (Fig.  167).  These  blind  ducts  are  lined  with 
a  single  layer  of  columnar  epithelium,  and  contain  an  inspis- 
sated green-coloured  material.  As  the  ducts  make  up  the 
bulk  of  the  tumour,  it  is  clear  that  the  olive-green  colour  of 
the  tumour  is  due  to  imprisoned  bile.  In  adenomas  of  this 
kind  the  columnar  cells  are  so  striking  that  some  observers 
have  described  these  tumours  as  columnar-celled  carcinomas 
of  the  liver.  In  other  specimens  the  cells,  instead  of  being 
arranged  in  this  tubular  fashion,  are  grouped  around  a  minute 
central  lumen  two  or  more  deep. 

So  far  as  our  knowledge  at  present  extends,  it  would 
appear  that  hepatic  adenomas  as  described  above  are  of  little 
clinical  importance,  and  they  have  been  found  during  the 
performance  of  a  post-mortem  examination  when  the  liver 
has  been  sliced  up  in  the  course  of  the  inspection.  Keen, 
however,  has  successfully  removed  a  hepatic  adenoma,  mea- 
suring 9  by  6  cm.,  from  a  woman  -31  years  of  age.  The 
circumstance  that  such  tumours  can  be  dealt  with  surgically 
will  lead,  in  all  probability,  to  an  extension  of  knowledge 
concerning  tliem. 

Carcinoma. — Hepatic  cancer  varies  greatly  in  its  exter- 
nal appearance ;  sometimes  it  assumes  the  form  of  compact, 
white  nodules  projecting  from  the  surface  of  the  liver  and 
visible  on  every  cut  surface,  the  nodules  varying  in  size 
from  a  marble,  or  ripe  cherry,  to  tumours  as  large  as  and 
even  exceeding  the  fist.  Many  of  the  surface  nodules  present 
a  central  depression  or  umbilicus. 

In  other  cases  the  cancer  assumes  the  form  of  an  irregular 
infiltration  of  soft  growth  of  an  olive  green;  some  of  the 
tracts  are  yellow.  In  all  cases  the  liver  is  enlarged,  sometimes 
to  twice  its  natural  size.  The  surface  is  in  most  cases  irregu- 
larly lobulated. 

Dissemination  of  hepatic  cancer  is  exceptional :  secondary 
nodules  have  been  found  in  the  lung,  and  cancerous  lymph- 
glands  in  the  portal  fissure;  in  one  of  the  cases  in  which 
secondary  nodules  occurred  in  the  lung,  the  mediastinal 
lympli-glands  were  enlarged  and  infiltrated  with  cancer. 

In  point  of  structure  hepatic  cancer  conforms  to  two  types, 
the  tahidar  and  the  acinous,  but  the  imitation  in  the  case  of 
cancer  is  not  so  good  as  with  hej)atic  adenoma. 


CANCER   OF  THE  LIVER  347 

Rindflleiscli,  in  reference  to  the  tubular  species  of  adenoma, 
writes : — "  The  pecuhar  intention  which  is  expressed  in  the 
whole  foundation  advances  to  a  delusive  imitation  of  a  tubular 
gland."  The  difference  between  the  tubular  adenoma  and  the 
tubular  carcinoma  is  that  the  imitation  is  still  more  delusive, 
and  this  is  equally  true  of  that  which  is  called  the  acinous 
species. 

Secondary  cancer  of  the  liver. — The  liver  plays  the  same 
part  in  the  portal  circulation  that  the  lungs  play  in  the 
pulmonary  circulation  when  any  viscus  or  organ  drained  by 
it  is  the  seat  of  carcinoma — namely,  to  act  as  a  filter  and 
deprive  it  of  cancer-emboli.  Like  the  lungs,  the  liver  also 
offers  an  extremely  favourable  territory  wherein  such  emi- 
grants may  thrive.  Secondary  cancerous  nodules  in  the  liver 
attain  larger  proportions  than  in  the  lung.  It  is  a  curious 
fact  that  in  many  cases  reported  as  primary  cancer  of  the 
liver  the  nodules  were  multiple.  This  is  a  very  exceptional 
condition  in  other  viscera,  which  renders  it  important,  before 
reporting  a  case  as  primary  cancer  of  the  liver,  to  make  a 
thorough  search  of  the  whole  intestinal  tract,  and  particularly 
of  the  rectum  and  anus,  when  conducting  a  post-mortem 
examination,  as  well  as  to  subject  the  hepatic  nodules  to  a 
careful  microscopic  examination. 

That  the  cancerous  nodules  on  the  surface  of  the  liver 
are  usually  umbilicated  is  due  to  degeneration  of  the  central 
cells  of  the  nodule,  which  then  become  compressed  by  the 
surrounding  fibrous  tissue. 

Occasionally  the  secondary  infection  of  the  liver  may 
as,sunie  the  form  of  one  large  central  mass  of  cancer,  which 
may  exceed  in  size  the  patient's  head.  Reference  has  already 
been  made  to  the  massiveness  of  secondary  cancerous  deposits 
in  the  liver,  and  some  explanation  offered  as  to  the  possible 
cause  of  their  luxuriant  growth  in  this  organ  (p.  260). 

Clinical  features. — Hepatic  cancer  occurs  equally  in  men 
and  in  women,  and  is  most  frequent  between  the  fortieth 
and  sixtieth  years.  It  is,  however,  liable  to  arise  at  a  much 
earlier  age ;  and  Acland  has  published  an  excellent  paper  on 
this  subject,  and  collected  nine  cases  of  primary  cancer  of 
the  liver  occurring  in  children  under  20  years  of  age.  All 
observers  agree  that  primary  cancer  of  the  liver  is  very  rare. 


348  EPITHELIAL   TUMOURS 

and,  as  is  the  case  with  many  rare  diseases,  there  is  very  httle 
rehable  evidence  forthcoming  concerning  it. 

Cancer  of  the  hver  leads  to  enlargement  of  this  gland  and 
to  jaundice,  which  may  be  slight  and  transient  or  of  great 
intensity;  in  a  few  cases  this  symptom  has  only  been  observed 
towards  the  termination  of  life.  Ascites  occurs  in  most  cases. 
The  available  facts  indicate  that  it  runs  a  very  rapid  course. 

An  important  clinical  feature  associated  with  the  rapid 
growth  of  secondary  cancer  in  the  liver,  especially  when  the 
primary  focus  is  in  the  large  intestine,  is  fever.  In  such  con- 
ditions the  body  temperature  may  rise  to  lOl*^',  103°,  and  even 
105^  Fahr. 

Cancer  of  the  liver  is  not  amenable  to  art,  either  medical 
or  surgical.  In  a  few,  very  few,  exceptional  instances  it  has 
been  possible  to  excise  a  cancerous  segment  of  the  liver,  and 
with  some  success. 

THE   GALL-BLADDER  AND  ITS  DUCTS 

Carcinoma  may  arise  in  any  part  of  the  canal  system  of 
the  liver,  from  the  minute  beginnings  in  the  hepatic  lobules 
to  its  termination  in  the  duodenum.  Cancer  is,  however,  more 
common  in  the  excretory  apparatus  than  in  the  liver  itself, 
and  it  occurs  more  frequently  in  the  gall-bladder  than  in  the 
hepatic  or  the  common  bile-duct.  The  clinical  features  of  the 
disease  differ  very  greatly  according  to  its  situation.  It  will 
be  convenient  to  consider  carcinoma  in  the  gall-bladder ;  in 
the  common  and  hepatic  ducts ;  and  in  the  ampulla  (diver- 
ticulum of  Vater). 

The  gall-bladder. — Cancer  arises  in  any  part  of  the 
mucous  membrane  of  the  gall-bladder,  and,  like  this  disease 
when  it  attacks  the  intestine,  may  project  into  the  cavity  as 
an  exuberant  fungating  growth,  or  infiltrate  its  walls  and 
spread  directly  into  the  subjacent  hepatic  tissue.  Cancer 
may  be  localized  to  the  fundus  of  the  gall-bladder,  and  bud- 
like processes  of  growth  will  perforate  its  walls,  and  the 
cells  from  the  surfaces  of  these  "  buds  "  give  rise  to  general 
cancerous  infection  of  the  peritoneum. 

It  is  not  uncommon  for  the  gall-bladder  to  be  implicated 
and  infected  with  cancer  of  the  liver,  both  primary  and  secon- 
dary ;  it  requires  some  care  to  discriminate  between  primary 


GANGER   OF  TEE   GALLBLADDER 


349 


cancer  of  the  gall-bladder  infiltrating  the  liver  and  cancer  of 
the  liver  implicating  the  gall-bladder.  In  some  instances  the 
distinction  cannot  be  made.  The  lymph-glancls  in  the  portal 
fissure  are  early  infected. 

The  type  of  cells  usually  found  in  cancer  of  the  gall- 
bladder is  columnar  or  subcolumnar.  When  the  walls  of  a 
cancerous  gall-bladder  are  firmly  compressed  on  the  contained 
calculi,  the  cells  of  the  mucous  membrane  flatten  and  assume 


CALCULUS 


Fig.  168. — Gall-bladder  with  primary  cancer  of  its  neck  extending  into  the  cystic 
duct ;  a  gall-stone  is  embedded  in  the  growth.  From  a  man  aged  70  years. 
{Museum,  Charing  Cross  Hospital.) 

the  characters  of  squamous  cells.  Cancer  in  a  gall-bladder  of 
this  kind  is  squamous-celled,  and  cell-nests  abound. 

The  most  important  feature  connected  with  primary  cancer 
of  the  gall-bladder  is  its  almost  constant  association  with 
gall-stones  (Figs.  168,  169,  170,  171).  Careful  investigations 
have  been  made  on  this  point,  and  prove  that  in  at  least  95 
per  cent,  of  the  cases  of  cancer  of  this  structure,  gall-stones 
are  present  also. 

Ten  years  ago  cancer  of  the  gall-bladder  was  considered 
a  rare  disease.     The  systematic  examination  of  gall-bladders 


350 


EPITHELIAL   TUMOURS 


removed  in  the  course  of  operations  for  gall-stones  proves 
that  it  is  a  common  affection.  Physiological  observation  has 
taught  us  that  the  liver,  in  addition  to  its  glycogenic  function, 
is  an  organic  filter,  for  it  separates  micro-organisms  from  the 
blood  conveyed  to  it  by  the  portal  vein  and  discharges  them 
with  the  bile.  Micro-organisms  eliminated  in  this  way  stimu- 
late the  epithelium  of  the  bile-passages  to  unnatural  growth. 


Fig.  169. — Caucer  of  the  gall-bladder  in  section.    {Micsetim  of  the  Middlesex  Hospital.) 

Infection  of  epithelium  causes  it  to  multiply :  this  is  ex- 
emplified in  the  gall-bladder.  Its  mucous  membrane  under 
normal  conditions  contains  few  glands,  but,  when  it  is  chroni- 
cally inflamed,  mucous  glands  become  abundant  and  of  large 
size.  In  cases  of  fistulte  between  gall-bladder  and  intestine 
the  mucous  membrane  becomes  thick  and  resembles  that  of 
the  intestine.  These  mucous  glands  are  important,  for  they 
are  the  chief  sources  of  the  calcium  found  in  mixed  biliary 


GANGER  OF  THE  BILE-DUCT 


351 


concretions.  It  is  undeniable  that  gall-stones  are  a  common 
complication  of  cancer  of  the  gall-bladder,  and  many  writers 
have  maintained  that  they  are  the  cause  of  the  cancerous 
change.  I  have  never  accepted  this  opinion,  preferring  to 
believe  that  the  pathological  conditions  of  the  epithelium 
lining  the  gall-bladder,  which  cause  it  to  produce  cholesterin 


Fis 


170. — Cancerous  and  calculous  gall-bladder  in  section,  showing  the  manner  in 
which  the  liver  is  infiltrated.      {2Iuseuiii  of  St.  Bartholomeiv''s  Hospital.) 


in  abundance,  increase  its  vulnerability  to  the  micro-parasite 
of  cancer. 

The  relations  of  gall-stones  to  cancer  vary  a  great  deal  ; 
in  some  the  walls  of  the  gall-bladder  are  greatly  thickened 
and  the  calculi  are  nested  together  in  the  centre  of  the  mass. 
In  other  cases  the  gall-bladder  is  filled  with  a  semi-pultaceous 
mass  of  soft  white  growth,  and  the  gall-stones  are  irregularly 


352 


EPITHELIAL    TUMOUES 


distributed  through  it.  In  other  instances  the  cancerous 
walls  of  the  gall-bladder  are  thick,  tough,  and  firmly  con- 
tracted on  a  set  of  gall-stones  which  completely  fill  it ;  yet 


Fig.  171.— Eularged  gall-bladder  removed  from  a  woman  aged  43  j-ears.  The 
cancer  had  burst  through  the  fundus  of  the  gall-bladder  and  imijlicated  the 
transverse  colon.  Eight  inches  of  the  latter  was  resected.  Several  hundred 
calculi,  consisting  almost  entirely  of  cholesterin,  were  joresent. 

the  organ  is  free  from  adhesions  and  mobile.  On  the  other 
hand,  it  may  be  tightly  contracted  on  a  solitary  gall-stone, 
and  the  cancer  so  infiltrate  the  liver  that  there  is  no  obvious 


Tee  common  and  hepatig  ducts  353 

indication  of  the   limit   between   the   gall-bladder   and   the 
hepatic  tissue. 

Primary  carcinoma  of  the  gall-bladder  is  more  common 
in  women  than  in  men  (three  to  one).  The  age  of  greatest 
liability  is  from  the  fiftieth  to  the  sixtieth  year.  It  runs  a 
ver}^  rapid  course,  and  is  usually  fatal  within  six  months  of 
the  onset  of  definite  symptoms.  The  chief  sign  of  the  disease 
is  the  presence  of  a  hard  swelling  in  the  region  of  the  gall- 
bladder. Jaundice  occurs  in  about  one-third  of  the  cases. 
Treatment. — The  removal  of  a  cancerous  gall-bladder  is 
not  an  encouraging  operation.  Out  of  eleven  cases  submitted 
to  operation  at  the  London  Hospital,  nine  died  (Slade).  By 
the  time  a  cancerous  gall-bladder  is  discovered  it  is  usually 
too  late  for  a  successful  operation. 

The  common  and  hepatic  ducts. — Primary  cancer  may 
arise  in  any  part  of  the  extrahepatic  ducts,  including  the 
ampulla ;  although  it  is  a  rare  disease,  there  are  many  care- 
fully reported  cases  and  specimens  available  for  reference, 
and  it  is  possible  to  furnish  an  account  of  its  chief  clinical 
and  pathological  features. 

Even  excluding  cancer  arising  in  the  ampulla,  the  common 
duct  is  the  one  most  frequently  affected,  and  in  a  fair  pro- 
portion of  cases  the  disease  is  situated  at  the  junction  of  the 
hepatic,  cystic,  and  common  ducts.  The  amount  of  growth  is 
small,  but  it  completely  blocks  the  duct  and  leads  to  dilata- 
tion of  the  canals  above  the  obstruction,  which  become  dis- 
tended with  bile,  and  later  in  the  course  of  the  case  this 
becomes  replaced  by  mucous  fluid  which  may  be  bile-stained. 
In  many  of  the  reported  cases  it  is  stated  that  there  was 
evidence  of  more  or  less  interstitial  biliary  fibrosis. 

Clinical  features. — Cancer  of  the  main  bile-ducts  appears 
to  be  most  common  between  the  fiftieth  and  sixtieth  years. 
The  symptoms  are  those  commonly  seen  in  primary  cancer 
of  the  head  of  the  pancreas  implicating  the  common  bile- 
duct,  such  as  jaundice,  progressive  emaciation,  and  occasionally 
enlargement  of  the  gall-bladder.  When  the  ampulla  is  can- 
cerous the  clinical  picture  would  be  the  same  in  the  two 
diseases.  The  distension  of  the  gall-bladder  in  this  disease 
is  of  some  importance,  because  cases  have  been  reported  in 
which  the  patients  died  from  acute  peritonitis  due  to  intra- 

X 


354  EPITEELIAL   TUMOURS 

peritoneal  rupture  of  the  gall-bladder.  (Cockle,  1883 ;  Coats 
and  Finlayson.) 

Gall-stones  have  been  found  in  cancerous  bile-ducts,  but 
tbe  association  is  uncommon. 

Pain  is  an  uncertain  feature :  it  is  well  to  remember  that 
a  gall-stone  may  painlessly  obstruct  the  common  bile-duct, 
producing  profound  jaundice;  on  the  other  hand,  cancer 
may  obstruct  the  duct  and  set  up  attacks  of  pain  re- 
sembling biliary  colic.  In  this  condition  the  patient  may 
suflPer  greatl}^  from  itching  of  the  skin. 

To  the  naked  eye,  cancer  of  the  common  bile-duct  looks 
like  a  knob  of  tough  fibrous  tissue,  or  the  duct  appears 
as  if  embedded  in  this  material,  but  on  microscopic  exa- 
mination the  cancer  is  seen  to  be  made  up  of  columnar 
or  spheroidal-shaped  epithelium.  In  some  specimens  the 
tubular  arrangement  is  obvious,  and  it  is  described  as  an 
adeno-carcinoma  (Parkes  Weber).  The  lymph-glands  in  the 
portal  fissure  may  be  enlarged. 

Carcinoma  of  the  ampulla. — It  is  possible  to  distinguish 
between  cancer  arising  in  the  common  duct  near  its  junction 
with  the  ampulla,  and  this  disease  starting  in  the  ej)ithelium 
lining  the  ampulla.  Cancer  in  either  situation  needs  to  be 
distinguished  from  the  same  disease  arising  in  the  duodenal 
epithelium  around  the  bile-papilla  (circumampullary  car- 
cinoma). 

From  a  practical  point  of  view  the  distinction  is  not  im- 
portant, except  in  the  particular  that  a  cancer  immediately 
above  the  ampulla  would  block  the  common  bile-duct  but 
need  not  block  the  pancreatic  duct,  whereas  a  growth  in  the 
ampulla  would  obstruct  the  flow  of  pancreatic  secretion  as 
well  as  of  bile. 

The  diagnosis  of  the  condition  is  beset  with  great 
difficulty,  as  this  disease  has  no  specific  sjnnptomatology. 
The  symptoms  are  homologous  with  those  produced  by 
cancer  of  the  head  of  the  pancreas;  primar}^  cancer  of  the 
duodenum,  involving  the  bile-papilla;  a  malignant  tumour 
of  the  stomach  involving  the  duct;  and  even  a  gall-stone 
impacted  in  the  ampulla.  It  is  also  impossible  to  distin- 
guish it  from  some  forms  of  disease  of  the  liver,  such  as 
carcinoma,  hypertrophic  biliary  cirrhosis,  or   even  infective 


GAEGINOMA   OF  TEE  AMPULLA  355 

jaundice,  and  the  pressure  of  an  ecliinococcus  cyst  or  can- 
cerous lymph -glands  in  the  portal  fissure. 

Treatment. — The  diagnosis  of  this  disease  being  very 
difiicult,  occasionally  the  uncertainty  is  cleared  up  by  an 
exploratory  operation. 

In  a  case  of  this  kind,  in  a  woman  aged  60  years,  under 
Osier's  care,  Halsted  found  a  carcinoma  of  the  ampulla ; 
he  excised  the  cancer,  the  bile-papilla  and  ampulla,  and 
the  adjacent  section  of  the  common  duct ;  the  cut  end  of 
the  duct  he  implanted  into  the  duodenum.  The  woman 
recovered  from  the  operation,  but  died  several  months  later 
from  recurrence  of  the  cancer  in  the  head  of  the  duodenum 
and  pancreas  {see  also  Kcirte). 

In  cases  where  an  exploratory  operation  has  been  per- 
formed, and  the  surgeon  finds  it  impossible  or,  in  considera- 
tion of  the  patient's  condition,  imprudent  to  attempt  a 
radical  operation,  it  is  sometimes  to  the  patient's  interest 
and  comfort  to  anastomose  the  gall-bladder  with  the  duo- 
denum, jejunum,  or  colon.  This  will  certainly  relieve  the  irri- 
tating minor  troubles  associated  with  the  jaundice,  although 
it  will  for  a  time  set  up  biliary  diarrhcea.  The  great 
danger  of  these  operations  in  cholsemic  patients  is  uncon- 
trollable oozing,  as  in  leukaemia. 

In  a  few  instances,  where  the  common  and  hepatic  ducts 
have  been  dilated  into  large  sacs  behind  an  inoperable 
complete  obstruction  of  the  common  bile-duct,  an  anastomosis 
between  the  sac  and  the  duodenum  has  been  succesfully 
effected  (choledochostomy). 

In  a  patient  in  whom  the  gall-bladder  was  too  small  to 
permit  cholecystenterostomy  for  the  relief  of  a  distressing 
jaundice,  Michels  performed  intrahepatic  cholangiostomy. 


THE   PANCREAS 

Carcinoma  of  the  pancreas  is  an  affection  ot  peculiar 
interest  because  it  is  in  itself  very  insidious,  and  rarely 
becomes  clinically  recognizable  except  from  what  may  be 
called  an  accident  in  its  environment,  namely,  the  disease  is 
very  prone  to  attack  the  head  of  the  gland  and  cause  jaundice 
by  obstructing  the  common  bile-duct. 


356  EPITHELIAL   TUMOURS 

The  pancreas  is  a  compound  gland,  for,  in  addition  to  its 
own  acini,  it  is  occupied  by  the  epithelial  bodies  known  as  the 
islands  of  Langerhans,  which  are  at  present  regarded  as  duct- 
less glands  furnishing  an  internal  secretion.  The  pancreas 
contains  three  distinct  sets  of  epithelial  structures;  these  are 
its  own  acini,  the  islands,  and  its  excretory  duct,  commonly 
known  as  the  duct  of  Wirsung.  Hillier  and  Goodall  have 
conducted  a  valuable  investigation  concerning  the  histology 
and  general  features  of  carcinoma  of  the  pancreas,  and  they 
have  come  to  the  conclusion  that  primary  cancer  of  this  gland 
may  arise  in  each  of  the  three  epithelial  structures  which  it 
contains.  The  common  type  is  spheroidal-celled  carcinoma 
with  a  large  amount  of  fibrous  tissue.  It  probably  arises  in 
the  acini  of  the  gland  and  is  comparable  to  spheroidal-celled 
cancer  of  the  breast.  The  second  variety  is  columnar-celled 
and  probably  arises  from  the  duct.  In  structure  this  kind 
resembles  primary  cancer  of  the  duodenum. 

The  third  variety  is  of  interest,  as  there  is  good  reason  to 
believe  that  it  arises  in  Langerhans'  islands:  "it  consists  of 
cells  most  irregular  in  size  and  shape,  but  on  the  whole  much 
larger  than  in  the  other  varieties  of  carcinoma,  and  possessed 
of  nuclei  which  in  some  instances  are  enormous." 

In  connexion  with  the  relation  of  the  islands  to  carcinoma, 
it  is  pointed  out  that,  in  the  ordinary  varieties  of  cancer  of 
the  pancreas,  the  islands  remain  unaffected  and  may  be  seen 
in  some  instances  surrounded  by  cancerous  growth ;  on  the 
other  hand,  when  the  pancreas  is  the  seat  of  secondary  cancer, 
the  islands  are  among  the  first  of  the  pancreatic  structures  to 
disappear. 

Cancer  of  the  pancreas  attacks  the  head  of  the  gland  six 
times  more  frequently  than  the  tail.  In  one  unusual  case  a 
cancerous  deposit  was  found  in  the  head  and  tail  of  the  same 
gland  (Hale  White).  Hillier  and  Goodall  observe  that  the  site 
of  origin  for  the  head  corresponds  closely  with  the  position  of 
the  junction  of  the  ducts  of  Wirsung  and  Santorini. 

Clinical  features. — The  difficulty  of  recognizing  cancer  of 
the  pancreas  is  increased  by  the  fact  that  the  tumour 
is  rarely  large  enough  to  be  appreciated  by  manipulation 
through  the  abdominal  wall.  Occasionally  the  tumour  will 
attain  the  dimensions  of  a  fist. 


GANGER   OF   THE  PANGBEAS  357 

The  disease  is  rare  before  middle  life,  and  it  attacks  both 
men  and  women.  The  chief  manifestation,  save  in  quite  the 
late  stages,  is  deep  jaundice,  often  unaccompanied  by  pain. 
As  the  disease  progresses  and  the  jaundice  deepens,  an  oval 
tumour  is  sometimes  appreciable  in  the  right  lumbar  region  ; 
this  is  the  over-distended  gall-bladder,  and  it  is  painless  to 
touch.  In  a  certain  proportion  of  cases  a  second  swelling  can 
be  made  out  in  the  region  of  the  head  of  the  pancreas.  This 
disease  is  rarely  a  source  of  pain,  but  in  some  cases  the  late 
stages  of  cancer  of  the  pancreas  are  accompanied  by  much 
suffering,  the  pain  occurring  in  severe  paroxysms. 

The  most  characteristic  feature  of  cancer  of  the  head  of 
the  pancreas  is  jaundice  unaccompanied  by  pain,  but  the 
icterus  in  these  circumstances  lacks  the  yellowness  which 
is  seen  when  the  common  bile-duct  alone  is  obstructed, 
for  it  has  a  brown  tint,  not  unlike  the  hue  of  the  skin  in 
Addison's  disease.  In  cases  where  the  jaundice  has  been 
relieved  by  diverting  the  bile  into  the  colon  this  brown  tint 
persists. 

Glycosuria  is  an  extremely  rare  complication  of  pancreatic 
cancer ;  its  variety  may  be  ascribed  to  the  fact  that  the  islands 
of  Langerhans  enjoy  considerable  immunity  from  the  disease. 
The  jaundice  is  accompanied  by  irritation  of  the  skin,  great 
depression,  slow  pulse,  and  emaciation.  The  wasting  in  a 
measure  depends  upon  the  altered  digestion  and  malassimila- 
tion,  due  to  the  absence  of  the  pancreatic  secretion  in  the 
alimentary  canal.  Death  usually  takes  place  from  coma,  the 
result  of  toxsemia,  and  not  infrequently  from  septic  phlebitis 
due  to  the  implication  of  the  large  veins  in  the  immediate 
neighbourhood  of  the  cceliac  axis.  It  is  a  curious  fact  that 
though  cancer  of  the  head  of  the  pancreas  quickly  involves  the 
common  bile-duct,  it  rarely  implicates  neighbouring  viscera 
such  as  the  duodenum  or  the  stomach.  Lymph-gland  infec- 
tion is  unusual,  and  dissemination  occasionallj^  occurs,  the 
secondary  nodules  being  found  in  the  liver  and  lung. 

Treatment.— The  insidious  character  of  the  disease,  the 
almost  inaccessible  situation  of  the  gland,  and  the  large  blood- 
and  lymph-vessels  in  its  neighbourhood,  do  not  favour  surgical 
enterprise.  On  one  occasion  I  diverted  the  bile  into  the  bowel 
by  anastomosing  the  distended  gall-bladder  with  the  hepatic 


358  EPITHELIAL   TUMOURS 

flexure  of  the  colon  in  a  case  of  pancreatic  cancer  with  jaun- 
dice, hoping  that  if  the  biliary  outflow  could  be  re-established 
life  might  be  prolonged.  It  was  not  successful.  In  the  case 
of  a  man  60  years  of  age,  with  primary  cancer  of  the  head 
of  the  pancreas,  I  succeeded  in  anastomosing  the  gall-bladder 
into  the  ascending  colon.  The  jaundice  disappeared,  but 
the  brown  tint  of  the  skin  remained  and  the  disease  ran  its 
deadly  course  uninfluenced.  The  patient  died  a  year  after 
the  operation. 

In  order  to  secure  the  full  benefit  of  an  operation  upon  a 
cancerous  pancreas,  it  would  be  essential  to  remove  the  whole 
gland.  This  in  itself  would  be  physiologically  disastrous, 
because  ex23eriments  on  animals  demonstrate  that  complete 
extirpation  of  the  pancreas  is  followed  by  diabetes. 

Acland,  T.  D.,  and  Dudgeon,  L.  S.,  "  Primaiy  Carcinoma  of  the  Liver :  very 
rapid  growth ;  great  emaciation  with  increase  in  body  weight ;  marked 
pyrexia ;  duration  four  months  (?)  ;  death." — Lancet,  1902,  ii.  1314. 

Coats,  J.,  and  Finlayson,  J.,  "  Cancer  of  the  Terminal  Part  of  the  Common 
Bile-Duct." — Path,  and  Clin.  Snc.  Trans.,  Glasgow,  iii.  144. 

Cockle,  "Cancer  of  the  Duodenum,  Suppuration  and  Perforation  of  the  Gall- 
Bladder,  followed  by  Fatal  Peritonitis." — Med.  Times,  1883,  p.  435. 

Halsted,  W.  S.,  '■  Contributions  to  the  Surgery  of  the  Bile-Passages,  especially 
of  the  Common  Bile-Duct." — Johns  Hopkins  Hosp.  Repts.,  1900,  xl.  1-11. 

Hillier,  W.  T.,  and  Goodall,  J.  S.,  "  The  Pancreas  in  Cases  of  Carcinoma." — 
Arch,  of  Middx.  Hosp.,  1904,  ii.  1. 

Keen,  W.  W.,  "  On  Eesection  of  the  Liver,  especially  for  Hepatic  Tumours." — 
Boston  Med.  and  Surg.  Journ. ,  1892,  cxxvi.  405. 

Keen,  W.  W.,  "  Report  of  a  Case  of  Eesection  of  the  Liver  for  the  Eemoval  of 
a  Neoplasm,  with  a  table  of  seventy-six  Cases  of  Eesection  of  the  Liver 
for  Hepatic  Tumour." — Ann.  of  Surg.,  1899,  xxx.  267. 

Kelynack,  T.  N.,  "  The  Eelation  of  Gall-Stones  to  Primary  Cancer  of  the  Gall- 
Bladder."— Praci^.,  1896,  Ivi.  387. 

Korte,  Prof.  W.,  Beit.  z.  Chirurgie  der  Gallenwege,  Berlin,  1905. 

Kidd,  Percy,  "  Primary  Cancer  of  the  Pancreas." — Trans.  Path.  Soc,  1883, 
xxxiv.  136. 

Moore,  N.,  "  Cancer  of  the  Pancreas."— >?#.  Bart.'s  Hosp.  Repts.,  1881,  xvii.  205. 

Paul,  F.  T.,  "  Cases  of  Adenoma  and  Primary  Carcinoma  of  the  Liver." — 
Trans.  Path.  Soc,  1885,  xxxvi.  238. 

Slade,  G.  R.,  "  Gall-Stones  and  CanceT."— Lancet,  1905,  i.  1052. 

Terrier  et  Auvray,  "  Les  Tumeurs  du  Foie  au  point  de  vue  Chirurgical :  litude 
sur  la  Eesection  du  Foie."— iZev.  de  Chir.,  1898,  xviii.  403,  706,  831. 


BEFEBENGE8  359 

Thompson,  J.  E.,  "The  Surgical  Treatment  of  Neoplasms  of  the  Liver." — 
Ann.  of  Surg.,  1899,  xxs.  284. 

Weber,  F.  P.,  and  Michels,  E.,  "  A  Case  of  Chronic  Jaundice  and  Great  En- 
largement of  the  Liver  due  to  Primary  Carcinoma  of  the  Extra-Hepatic 
Bile-Ducts  commencing  at  the  Junction  of  the  Hepatic  Ducts." — Med. 
Chir.  Trans.,  1905,  Ixxxviii.  247. 

White,  W.  Hale,  "  On  Primary  Malignant  Disease  of  the  Liver." —  Guys  Hosp. 
Repts.,  1894,  xlvii.  59. 

White,  W.  Hale,  "  Carcinoma  of  the  Pancreas." — Clin.  Joiorn.,  1900,  xvi.  97. 


CHAPTER  XXXV 

CARCINOMA    OF   THE    URINARY   AND 
EXTERNAL   GENITAL   ORGANS 

THE   URINARY   ORGANS 

Evert  part  of  the  urinary  system  is  liable  to  cancer — kidney, 
ureter,  bladder,  prostate,  and  urethra.     It  is  common  in  the 


Fig.  172. — Cancerous  kidney  in  section.     From  a  man  54  years  of  age. 

bladder;     next    in    order    of  frequency   come   the  complex 


360 


GANGER   OF  THE  KIDNEY 


361 


glandular  organs — the  kidney  and  prostate.  It  is  rarest  in 
the  conduits — the  ureter  and  the  urethra. 

We  shall  find  it  convenient  to  consider  each  part  in  ana- 
tomical sequence,  beginning  with  the  kidney. 

Cancer  of  the  kidney. — Carcinoma  of  this  organ  starts 
in  the  epithelium  of  the  uriniferous  tubules,  and  gradually 
transforms  the  renal  tissue  without  violently  distorting  the 
shape  of  the  gland  (Fig.  172).  The  cancerous  tissue  creeps 
into   the   pelvis  of  the   kidney   and  invades  the  ureter,  ex- 


Fig.  173.—  Microscopic  characters  of  renal  cancer. 

tending  sometimes  the  whole  length  of  the  duct,  and  the  out- 
runner has  been  observed  to  enter  the  bladder.  This  relation 
of  the  carcinoma  to  the  ureter  explains  the  frequency  of 
hgematuria  as  a  concomitant  of  this  disease. 

The  minute  characters  of  renal  carcinoma  are  very  strik- 
ing, and  consist  of  tubules  lined  with  regularly  arranged 
columnar  epithelium  (Fig.  173),  and  the  general  arrangement 
of  these  tubules  in  microscopic  sections  presents  "  a  rough 
but  striking  resemblance  to  the  tubular  structure  of  the 
kidney  "  (Sharkey). 

Our   knowledge   of   the   oreneral  characters  of  renal  car- 


362 


EPITHELIAL   TUMOURS 


cinoma  is  very  limited,  because  it  is  only  during  the  last  ten 
years  that  any  serious  efforts  have  been  made  to  separate  the 
epithelial  malignant  tumours  (carcinoma)  of  the  kidney  from 
the  connective- tissue  (sarcomatous)  tumours,  which  are  by 
far  the  most  common  form  of  malignant  tumours  that  attack 
this  gland. 

Renal  carcinoma  is  uncommon  before  middle  life  and  in- 
creases  in  frequency  after   the  fiftieth  year,  and  is  usually 


Fig.  174. — Horseshoe  kidney  ;  one  half  of  the  organ  is  the  seat  of  carcinoma. 
From  a  woman  60  years  of  age.     {Mmeion,  Eoyal  College  of  Surgeons.) 

limited  to  one  kidney.  The  unilateral  character  comes  out 
strongly  when  the  disease  attacks  a  horseshoe  kidney,  for 
even  under  these  conditions  it  remains  restricted  to  one  halt 
of  the  compound  gland  (Fig.  174). 

Cancer  of  the  kidney  is  a  very  deadly  disease,  and  a  careful 
study  of  the  records  relating  to  cases  in  which  the  his- 
tology of  the  tumour  was  carefully  determined  shows  that 
many  of  the  patients  from  whom  the  kidney  is  removed 
die  from  the  direct  effects  of  the  operation.  This  is  partly 
due  to  the  exhausting  effects  of  the  cancer  and  hsematuria 


GANGER   OF  THE   UBETEE  AND  BLADDER  363 

upon  individuals  advanced  in  life.  Of  the  patients  who  re- 
cover from  the  operation,  it  is  exceptional  for  life  to  be 
prolonged  more  than  a  year. 

Cancer  of  the  ureter. — The  terminal  orifices  of  ducts  are 
not  uncommon  situations  for  primary  cancer,  e.g.  the  duodenal 
end  of  the  bile-duct,  the  urethral  orifice  in  both  sexes,  and 
the  vesical  as  well  as  the  dilated  or  pelvic  portion  of  the 
ureters.  It  is,  however,  rare  for  cancer  to  arise  in  any  part 
of  the  ureter  between  the  renal  pelvis  and  the  bladder. 
Voelcker  has  recorded  a  case  in  which  a  primary  carci- 
noma arose  in  the  right  ureter  at  the  spot  where  it  crosses 
the  brim  of  the  pelvis.  The  patient,  a  man  68  years  of  age, 
came  under  observation  on  account  of  hsematuria.  At  the 
post-mortem  examination  a  tumour  as  big  as  a  cherry,  which 
on  microscopic  examination  furnished  the  characters  of 
carcinoma,  was  found  in  the  ureter.  The  lymph-glands  on 
the  corresponding  side  of  the  aorta  were  infected.  There  was 
a  large  secondary  mass  of  cancer  in  the  liver,  and  there  were 
nodules  in  the  right  lung,  which  agreed  in  their  microscopic 
characters  with  the  tumour  in  the  ureter. 

Cancer  of  the  bladder.— In  this  viscus  cancer  is  of  the 
squamous-celled  variety,  and  arises  in  the  mucous  membrane. 
From  what  is  known  of  the  habits  of  this  disease  elsewhere,  it 
would,  be  anticipated  that  in  a  certain  proportion  of  cases  it 
would  begin  at  the  orifices  of  the  ureters.  This  is  actually 
the  case ;  but  it  must  not  be  assumed,  when  the  ureteral 
orifices  are  found  involved  in  the  late  stages,  that  the  disease 
originated  at  these  orifices. 

Cancer  of  the  bladder  seems  to  be  more  common  in  women 
than  in  men.  The  signs  of  its  presence  are  hi3ematuria,  painful 
micturition,  and  cystitis.  Such  signs  are,  of  course,  equivocal, 
and  its  presence  is  demonstrated  by  means  of  the  cysto- 
cope.  It  is  very  unusual  before  the  age  of  40.  Death  results 
from  renal  complications,  exhaustion  from  repeated  bleeding, 
bodily  suffering,  and  frequent  micturition. 

Carcinoma  has  been  observed  on  an  extroverted  bladder ; 
the  patient  was  a  man  aged  60,  who  "  had  always  earned  his 
living  by  cracking  stones"  (NeAvland). 

Treatment. — Operations  on  the  bladder  are  of  two  kinds : 
(1)  those  which  are  performed  to  relieve  the  patient  of  the 


364  EPITHELIAL   TUMOURS 

frequency  of  micturition  and  the  attendant  pain,  and  (2)  those 
which  are  directed  to  the  extirpation  of  the  cancer. 

Operation  of  the  first  kind  consists  of  cystotomy,  either 
through  the  perineum  or  above  the  pubes.  I  have  found  the 
best  consequences  follow  a  suprapubic  opening.  The  urine 
flows  away  as  soon  as  it  enters  the  bladder,  and  the  patient 
quickly  learns  to  manage  the  necessary  tube  and  receptacle, 
and  is  not  obliged  to  remain  in  bed. 

The  more  radical  treatment  consists  either  in  removal  of 
the  tumour  with  the  implicated  segment  of  the  bladder,  or  in 
complete  extirpation  of  the  vise  us.  In  the  case  of  women  the 
ureters  have  been  diverted  into  the  vagina,  and  in  the  case  of 
men  into  the  rectum.  It  is  a  fact  of  some  value  that  the 
rectum  will  accommodate  a  fairly  large  quantity  of  urine  under 
such  conditions.  The  results  of  complete  removal  of  the 
bladder  are  not  encouraging.  Partial  resection  of  the  bladder 
is  attended  with  better  consequences,  especially  when  the 
tumour  is  situated  on  or  near  its  summit.  Operative  treat- 
ment of  bladder-tumours  is  necessarily  restricted,  because  in 
the  majority  of  cases  the  tumour  arises  in  the  vicinity  of  the 
ureteral  orifices. 

Cancer  of  the  urethra. — ^This  is  an  extremely  rare  situa- 
tion for  cancer.  Nevertheless,  there  are  some  carefully 
recorded  cases.  The  disease  is  of  the  squamous-celled  variety, 
and  usually  arises  in  that  part  of  the  urethra  which  is  in 
relation  with  the  bulb.  The  patients  were  between  the  ages 
of  50  and  73.  The  trouble  in  each  instance  attracted  atten- 
tion as  a  hard  mass  in  the  perineum  which  interfered  with 
micturition,  and  attempts  to  pass  a  catheter  provoked  great 
pain  and  induced  free  bleeding.  The  obstruction  increased 
until  the  urethra  became  impermeable  and  fistulse  formed  in 
the  perineum.  In  most  of  the  cases  perineal  section  was 
performed,  and  the  cut  surface  of  the  tumour  had  a  greyish- 
white  appearance  and  was  extremely  brittle. 

Cancer  of  the  urethra  occurs,  though  rarely,  in  women :  it 
may  be  of  the  columnar-celled  or  the  squamous-celled  type. 
The  first  variety  ma}^  arise  in  the  urethral  recesses  known 
as  Skene's  tubes. 

The  free  removal  of  the  urethra  in  women  for  carcinoma 
usually  entails  incontinence  of  urine.     (See  Boyd.) 


SWEEP'S  GANGER  '  365 

Cancer  of  the  prostate. — The  prostate  is  occasionally 
affected  by  cancer,  especially  in  old  men.  As  the  disease 
advances  it  extends  beyond  the  prostate  and  infiltrates  the 
tissues  around  the  base  of  the  bladder.  The  pelvic  lymph- 
glands  become  infected,  and  dissemination  is  common.  It 
would  appear  that  secondary  deposits  in  bone  are  a  very  con- 
stant feature  of  prostatic  cancer,  and  it  has  been  particularly 
studied  by  von  Recklinghausen. 

The  radical  treatment  of  cancer  of  the  prostate  is  beyond 
surgical  art. 

The  enlargement  of  the  prostate,  which  is  so  common 
after  middle  life,  and  is  often  termed  prostatic  adenoma,  is  the 
result  of  a  slow,  chronic  inflammatory  change.  This  subject 
has  been  very  thoroughly  handled  by  Ciechanowski  (1903). 

THE  EXTERNAL   GENITAL   ORGANS 

The  greater  part  of  the  external  genital  organs  are  directly 
continuous  with  and  derived  from  the  skin ;  they  are  liable 
to  squamous-celled  cancer. 

Cancer  of  the  scrotum  (sweep's  cancer). — This  appears 
on  the  scrotum  in  the  form  of  a  wart  or  warts ;  they  are  often 
spoken  of  as  soot-warts,  for  they  not  only  occur  on  the  scrotum 
of  the  chimney-sweep,  but  are  met  with  in  men  who  are 
brought  much  in  contact  with  soot.  In  many  cases  the 
scrotal  wart  is  harmless,  but  in  a  certain  proportion  of  cases 
it  grows  slowly,  or  if  multiple,  one  becomes  more  prominent 
than  its  fellows  and  ulcerates.  The  ulceration,  at  first  limited 
to  the  wart,  extends  to  the  surrounding  skin  and  forms  a 
cancerous  ulcer,  which  will  extensively  involve  the  scrotum, 
spread  thence  to  the  skin  around  the  anus  and  pubes,  and 
even  to  the  thigh.  In  some  cases  the  ulceration,  instead  of 
spreading  widely,  involves  the  tissues  deeply,  so  that  the 
tunica  vaginalis  is  exposed  and  sometimes  implicated  in  the 
disease  ;  but  this  is  rare. 

The  inguinal  glands  become  infected  and  attain  a  large 
size^  then  slowly  involve  the  skin,  break  down  and  ulcerate. 
This  process  often  leads  to  the  formation  of  deep  excavations 
in  the  groin,  and  it  not  infrequently  happens  that  the  femoral 
or  the  external  iliac  artery,  or  both,  will  be  seen  exposed  and 


366  EPITHELIAL   TUMOUBS 

pulsating  on  the  floor  of  one  of  these  deep  pits.  It  is  not 
uncommon  in  such  cases  for  the  ulceration  to  open  up  one 
of  these  large  vessels,  and  violent,  fatal  hsemorrhage  is  the 
result. 

It  has  been  stated  by  several  writers  that  in  chimney- 
sweeps cancer  may  begin  in  the  inguinal  glands.  There  can 
be  little  doubt  that  such  views  arise  in  imperfect  observation. 
In  some  of  these  cases  the  lesion  on  the  scrotum  assumes  the 
form  of  a  small  hemispherical  pimple  no  larger  than  a  split 
pea — so  small,  indeed,  that  I  have  known  it  escape  very 
vigilant  eyes — and  yet  such  a  small  lesion  will  cause  the 
inguinal  lymph-glands  to  grow  into  a  mass  fully  as  big  as 
two  fists.  Two  cases  of  this  kind  have  come  under  my 
own  notice. 

A  very  remarkable  feature  connected  with  cancer  in  English 
chimney-sweejjs  is,  that  they  are  not  more  prone  to  it  in 
other  parts  of  their  bodies  than  those  persons  who  follow 
other  occupations ;  yet  the  scrotum,  which  in  other  indi- 
viduals is  the  part  least  disposed  to  cancer,  is  in  sweeps  so 
very  hable  to  become  the  seat  of  this  disease.  No  answer  to 
this  problem  is  at  present  forthcoming ;  neither  has  anyone 
succeeded  in  assigning  a  reason  why  it  is  so  very  much  more 
frequent  m  English  chimney-sweeps  than  in  sweeps  of  other 
nations. 

There  is  good  reason  to  believe  that  tar  and  paraffin  are 
liable  to  produce  an  affection  of  the  scrotum  similar  to 
sweep's  cancer.  Such  cases  are,  however,  very  rare.  The 
literature  has  been  summarized  by  Butlin. 

Treatment. — This  consists  in  the  free  removal  of  the 
disease  whenever  it  is  practicable  ;  the  very  best  results  follow 
the  excision  of  a  soot-wart  in  its  earliest  stages.  When  the 
disease  is  permitted  to  extend  deeply  into  the  tissues  of  the 
scrotum,  so  that  it  is  necessary  to  excise  one  or  both  testicles 
with  the  scrotum,  and  perhaps  a  portion  of  the  neighbouring 
skin,  it  is  not  probable  that  lasting  benefit  will  follow  the 
operation.  In  cases  where  soot-warts  have  been  early  and 
thoroughly  removed  there  is  good  ground  for  the  belief  that  a 
cure  is  sometimes  brouo-ht  about. 

Cancer  of  the  testis, —  This  subject  is  discussed  in 
Chap.  Liii. 


GANGER   OF  TEE  PENIS  367 

Cancer  of  the  penis. — This  disease  may  attack  the  prepuce 
or  the  epithelial  investment  of  the  glans.  Carcinoma  arising 
in  the  epithelium  of  the  urethra  is  considered  on  p.  364.  The 
disease  is  excessively  rare  before  the  age  of  30  years,  and 
appears  to  be  most  common  between  the  ages  of  50  and  70. 
Phimosis,  congenital  or  acquired,  appears  to  be  a  condition 
that  favours  cancer  of  the  penis.  It  is  certainly  true  that 
phimosis,  by  leading  to  the  retention  of  smegma,  is  indirectly 
a  cause  of  penile  warts  not  only  in  men  but  other  mammals, 
especially  horses  and  bulls.  Mention  has  already  been  made 
of  the  fact  that  penile  warts  are  particularly  prone  to  be  trans- 
formed into  wart-horns,  and  cases  have  been  recorded  in  which 
men  have  had  a  wart-horn  on  the  penis  for  several  years,  and 
at  length  its  base  has  become  the  starting-jDoint  of  cancer.  It 
must  be  remembered  that  cancer  may  begin  as  an  ulcer  on 
the  penis,  but  the  warty  variety  is  by  far  the  more  frequent. 
When  the  disease  begins  as  an  ulcer,  it  is  very  liable  to  be 
mistaken  for  some  manifestation  of  primary  or  tertiary 
syphilis.  On  the  other  hand,  very  great  care  must  be  taken 
not  to  mistake  a  breaking-down  gumma  of  the  glans  penis 
for  cancer. 

Cancer,  in  whatever  form  it  begins,  gradually  involves 
and  as  surely  destroys  the  penis,  implicates  the  scrotum, 
and  infects  the  inguinal  lymph-glands  on  each  side ;  in  many 
cases  the  lumbar  glands  also  become  infected.  Secondary 
deposits  seem  to  be  rare.  The  duration  of  life  in  this 
disease  is  very  uncertain.  As  a  rule,  its  course  is  short — six 
months  to  a  year ;  but  in  many  cases  it  is  much  longer. 
When  the  urethra  is  involved  this  passage  becomes  narrowed, 
and  not  infrequently  urinary  fistula3  add  to  the  patient's 
misery. 

Cancer  of  Cowper's  glands. — These  structures  are  liable 
to  inflame  and  become  cystic,  and  there  is  also  reason  to 
believe  that  the  gland  may  become  cancerous.  The  most 
recent  contribution  to  the  subject  is  by  Witsenhausen. 

Treatment.- — Cancer  of  the  penis  is  treated  by  partial  or 
complete  removal  of  this  organ,  according  to  the  extent  of  the 
disease.  Partial  removal  of  the  penis  is  a  simple  proceeding, 
and  entails  but  little  risk  so  long  as  the  cut  end  of  the 
urethra   is   stitched  to  the  skin.     When   the   disease   is   so 


368  EPITHELIAL    TIJMOUBS 

extensive  as  to  demand  complete  removal  of  the  penis,  the 
operation  which  gives  best  results  consists  in  excising  not 
only  the  corpus  spongiosum  and  corpora  cavernosa,  but  the 
penile  crura  as  well,  by  detaching  them  from  the  pubic  arch. 
The  urethra  is  brought  out  and  attached  to  the  incision  in 
the  perineum.  In  all  cases  where  it  is  justifiable  to  amputate 
or  extirpate  the  penis  for  cancer  the  infected  inguinal  lymph- 
glands  should  be  thoroughly  removed.  The  published  results 
of  this  complete  operation  are  very  good,  and  my  experience 
of  it  has  been  in  ever}^  way  satisfactory.  The  ultimate  results 
of  amputation  of  the  penis  are  more  favourable  after  partial 
than  after  complete  removal  of  the  organ,  simply  because 
the  disease  is  not  so  advanced  when  partial  amputation  is 
sufficient. 

Cancer  of  the  vulva  and  vagina.  —  The  variety  of 
cancer  which  attacks  the  external  genital  organs  of  the  female, 
with  the  exception  of  Bartholin's  glands,  is  squamous-celled. 

Collectively,  cancer  of  these  parts  is  not  uncommon,  but 
when  each  part  is  individually  considered,  then  it  is  compara- 
tively rare.  The  disease  is  more  frequent  in  the  labia  than 
in  all  other  parts  of  the  genital  passage  taken  together. 

The  labia  majora  and  minora. — Carcinoma  may  begin  on 
any  part  of  the  labia,  but  it  generally  attacks  the  opposed, 
or  so-called  mucous,  surfaces.  In  many  cases  this  is  preceded 
by  leukoplakia,  identical  in  appearance  and  structure  with 
lingual  leukoplakia. 

Careful  inquiries  in  London  indicate  that  cancer  of  the 
vulva  is  as  common  as  cancer  of  the  lip  in  men.  During 
the  decade  1898-1908  fifty-eight  women  were  admitted  into 
the  Chelsea  Hospital  for  Women  and  the  Middlesex  Hospital 
with  carcinoma  of  the  vulva,  and  in  all  the  patients  the 
inner  surfaces  of  the  labia  majora  presented  the  condition 
known  as  leukoplakia.  When  the  social  histories  of  these 
women  are  analysed  they  are  instructive,  because  among 
the  fifty-eight  patients  there  were  sixteen  widows,  thirty- 
four  married  women,  and  eight  spinsters.  These  observations 
indicate  that  trauma  connected  with  coition  and  childbirth 
are  probably  factors  in  producing  the  changes  which  render 
the  epithelial  tissues  of  the  vulva  liable  to  cancer. 

The  relation  of  leukoplakic  vulvitis  and  kraurosis  of  the 


GANGER   OF  TEE    VULVA  369 

vulva  to  cancer  lias  been  carefully  investigated  by  Comyns 
Berkeley  and  Victor  Bonney.  In  this  valuable  monograph 
they  point  out  that  kraurosis  is  not  a  forerunner  of  cancer. 

It  is  a  significant  feature  in  relation  to  vulvar  cancer  that 
trauma  connected  with  the  sexual  act  and  its  results  plays 
the  same  part  in  connexion  with  the  labia  that  the  habit  of 
smoking  short,  dirty  clay  pipes  exercises  on  the  mucous 
membrane  of  the  lips. 

The  disease  runs  a  course  very  similar  to  squamous-celled 
cancer  of  the  scrotum.  When  recognized  in  the  early 
stages,  prompt  and  free  excision  and  removal  of  the  infected 
inguinal  lymph-glands  is  followed  by  much  the  same  suc- 
cess which  attends  operations  upon  cancer  of  the  lip.  In 
operating  for  cancer  of  the  vulva  the  method  which  has 
given  me  the  best  results,  immediate  and  remote,  consists  in 
freely  excising  the  primary  disease  with  the  scalpel.  Healing 
usually  takes  place  in  fourteen  days.  The  lymph-glands,  large 
and  small,  are  then  removed  from  both  inguinal  regions. 
Dividing  the  operation  in  this  way  avoids  the  risk  of  sepsis 
and  diminishes  shock  and  hsemorrhage,  for  in  many  instances 
operations  on  the  vulva  are  attended  with  free  bleeding. 

The  clitoris.— Cancer  of  this  organ  is  a  rare  disease;  the 
majority  of  the  patients  are  over  50  years  of  age.  One 
example  has  come  under  my  notice,  and  in  this  the  disease 
began  at  the  free  extremity  of  the  clitoris,  in  a  woman  45 
years  of  age. 

The  treatment  consists  in  free  removal  of  the  clitoris  and 
its  crura,  and  removal  of  infected  inguinal  lymph-glands.  If 
the  operation  is  carried  out  before  the  disease  has  extended 
to  the  nymphse,  labia,  or  mons,  the  outlook  for  the  patient  is 
favourable. 

Bjorkquist  has  collected  sixty-seven  cases  from  the  litera- 
ture. He  considers  the  prognosis  grave :  in  twenty  patients 
death  occurred  in  sixteen  months. 

The  vagina. — Carcinoma  may  attack  any  part  of  the 
mucous  membrane  hning  this  canal,  but  it  is  much  more 
prone  to  begin  at  the  vulvo -vaginal  junction.  In  the  majority 
of  cases  which  have  come  under  my  observation  the  cancer  has 
been  in  the  immediate  vicinity  of  the  urethral  oriiice.  In 
every  instance  the  patients  were  past  middle  life,  and  one  was 

Y 


S70  EPI'TliELlAtj    TtJMOURS 

73  years  old.  The  inguinal  lymph-glands  are  early  infected. 
The  cancer  quickly  implicates  the  vesico-vaginal  septum  and 
leads  to  fistula,  and  when  it  attacks  the  posterior  wall  it 
causes  a  recto-vaginal  fistula.  In  one  case  the  urethral  orifice 
became  blocked  with  cancerous  granulation,  and  retention  of 
urine  was  a  very  distressing  symptom. 

In  the  early  stages  cancer  of  the  vagina  produces  so 
little  inconvenience  that  the  patients  do  not  seek  advice  until 
the  disease  is  far  advanced.  Surgery  can  do  little  in  cancer 
of  the  vagina,  for  even  in  the  very  early  stages  free  removal 
may  anticipate  some  of  the  evils  of  the  disease  by  establishing 
a  vesical  or  a  rectal  fistula. 

Cancer  of  the  vagina  is  rare ;  for  example,  in  the  quin- 
quennium 1904-8  three  patients  with  cancer  of  the  vagina 
died  in  the  Middlesex  Hospital.  During  the  same  period 
241  women  with  cancer  of  the  neck  of  the  uterus  were 
admitted  to  the  general  wards  and  to  the  Cancer  Asylum 
of  this  hospital.  {Eighth  Report  of  the  Cancer  Research 
Laboratories.) 

Bartholin's  glands. — It  is  well  known  that  these  glands 
are  very  liable  to  become  cystic ;  they  are  prone,  too,  to 
septic  infeation.  They  are  also  occasionally  the  source  of 
cancer.  Schweizer  has  reported  a  case  and  collected  the 
literature. 


Beck,  Marcus,  "A  Case  of  Primary  Squamous  Carcinoma  of  the  Bulbous 
Portion  of  the  Urethra." — Internat.  Clinics,  1893,  ii.  256. 

Berkeley,  Comyns,  and  Bonney,  V.,  "Leucoplakic  Vulvitis  and  its  Eelation  to 
Kraurosis  Vulvae  and  Carcinoma  Vulvse." — Brit.  Med.  Journ.,  1910,  ii.  1739 

Bjorkquist,  "  Festschrift  gewidmet  Otto  Engstrom,"  Berlin,  1903. 

Boyd,  Mrs.,  "  Tvfo  Cases  of  Primary  Carcinoma  of  the  Female  Urethra." — 
Journ.  of  Oistet.  and  Gyn.,  1906,  ix.  40. 

Butlin,  H.  T.,  "  Cancer  of  the  Scrotum  in  Chimney-Sweei^s." — Brit.  Med. 
Journ.,  1892,  i.  1341. 

Ciechanowski,  S.,  "  Anatomical  Researches  on  the  so-called  Prostatic  Hyper- 
trophy," 1903. 

Dittrick,  H.,  "  Epithelioma  of  the  Vulva,  with  references  to  the  Literature." — 
Amer.  Journ.  of  the  Med.  ScL,  1905,  cxxx.  277. 

Griflaths,  J.,  "  Epithelioma  of  the  Male  Urethra." — Travis.  Path.  Soc,  1889, 
xl.  177. 


BEFEBENGES  371 

Newland,  H.  S.,  "  Extroversion  of  the  Bladder." — Brit.  Med.  Journ.,  1906, 
i.  9G6. 

von  Recklinghausen,  F.,  "  Die  fibrose  oder  deformirende  Ostitis,  die  Osteo- 
malacia, und  die  Osteoplastische  Carcinose  in  ihren  gegenseitigen 
Beziehungen." — Festschrift  Rudolf  Virchow  zu  seinern  71  Geburtstage 
gewidmet,  Berlin,  1891. 

Schweizer,  Fritz,  "  CarcinomderBartholiniscbenDriise." — Arcli.f.  Gyn.,  1S93, 
xliv.  322, 

Tuffier  et  Dujarier,  "Extirpation  Totale  de  la  Vessie." — Rev.  do  Chir.,  1898, 
xviii.  279. 

Voelcker,  A.  F.,  "  Primary  Carcinoma  of  the  Ureter." — Trans.  Path.  Soc,  1895, 
xlvi.  133. 

Witsenhausen,  0.,  "Das  Primare  Carcinom  der  Urethra." — Beit.  z.  Idin.  Chir., 
1891,  vii.  571. 


CHAPTER    XXXVI 

EPITHELIAL   TUMOURS   OF    THE    UTERUS 

The  endometrium  of  the  cervical  canal  and  body  of  the 
uterus  is  covered  with  columnar  epithelium ;  it  is  continued 
through  the  Fallopian  tubes  to  end  at  their  coelomic  ostia, 


Fig.  175. — Microscopic  characters  of  the  pink  tissue  at  the  neck  of  the  uterus, 
commonly  called  an  "  erosion."     {After  Bonney.) 

where  there  is  an  abrupt  transition  to  the  pavement-like 
epithelium  (endothelium)  of  the  peritoneum.  The  epithelium 
of  the  cervical  endometrium  undergoes  transformation  at 
the  external  mouth  (or  os)  of  the  uterus  into  the  stratified 
or  squamous-celled  type  which  lines  the  vagina.  The 
columnar  cells  within  the  uterus  and  Fallopian  tubes  are 
ciliated.  Changes  occur  throughout  any  portion  of  this 
epithelial  tract,  but  vulnerability  of  the  epithelium  varies 
greatly  in  the  different  regions. 

372 


ADENOMA   OF   THE    UTERUS 


373 


It  will  be  convenient  to  study  the  epithelial  changes 
which  are  non-malignant  before  considering  those  of  a 
cancerous  kind. 

Adenomas. — The  endometrium  of  the  cervical  canal  is 
furnished  with  numerous  racemose  glands.  Adenomas, 
which  are  structurally  repetitions  of  these  glands,  are  very 
common  at  the  neck  of  the  uterus;  they  may  be  sessile 
or  pedunculated. 

A  sessile  adenoma  appears  as  a  soft  velvety  areola 
around  the  os;  it  is  in  colour  like  a  ripe  strawberry,  and 
thickly  dotted  with  minute  spots  of  a  brighter  pink.     This 


Fig.  176. — Tubular  glands  of  the  corporeal  endometrium  in  transverse  section. 


pink  tissue  is  composed  of  glandular  acini  lined  with  large, 
regular,  columnar  epithelium  (Fig.  175).  The  glandular  tissue 
often  extends  beyond  the  margins  of  the  os  and  invades  the 
vaginal  portion  of  the  cervix.  Sometimes  it  is  so  abundant 
that  the  apex  of  the  cervix,  instead  of  being  a  cone,  assumes 
rather  the  shape  of  the  under  surface  of  a  mushroom.  The 
glandular  mass  is  not  confined  to  the  margins  of  the  os,  but 
extends  for  a  variable  distance  up  the  canal.  When  adenoma 
affects  a  lacerated  cervix  the  whole  of  the  exposed  portion  of 
the  canal  is  involved.     The  surface  of  a  sessile  adenoma  is 


374 


EPITHELIAL  TUMOURS 


covered    witli   tenacious   mucus   secreted    by   the    abnormal 
glands. 

Pedunculated  adenomas  are  rarely  large  :  they  may  grow 
from  any  part  of  the  cervical  canal,  but  are  most  frequently 
found  springing  from  the  lower  2  cm.  of  the  canal.  As  a  rule 
they  occur  singly,  but  two  or  more  may  be  present.     They 


Fig.  177. — Uterus  with  villous  disease  of  the  endometrium.    Removed  from  a  multi- 
para aged  83.     The  patient  was  alive  and  in  good  health  three  years  later. 

are  soft  and  velvety  to  the  touch,  and  dotted  with  minute 
pores.  They  consist  of  an  axis  of  fibrous  issue,  covered  with 
mucous  membrane  continuous  with  that  lining  the  cervical 
canal.  When  these  pedunculated  adenomas  (polypi)  remain 
within  the  canal,  the  epithelium  covering  them  and  the  glands 
they  contain  are  of  the  same  character  as  those  of  the  cervical 
mucous  membrane.  When  the  tumours  increase  in  size  and 
project  into  the  vagina,  the  epithelium  covering  the  protruding 
portions  becomes  stratified  and  the  glands  disappear. 


ABENO-MYOMA   OF  THE  UTERUS 


375 


Adenomas  growing  from  the  corporeal  endometrium  are 
pedunculated,  and  so  soft  that  they  are  often  termed  mucous 
polypi. 

Microscopically  these  tumours  consist  of  cystic  spaces 
lined  with  columnar  epithelium,  the  cavities  being  filled 
with  mucus.  Adenomas  of  the  corporeal  endometrium 
differ  from  those  of  the  cervix  in  that  the  cystic  spaces 
are  larger  and   more  numerous  (Fig.  176). 


Fig.  178. — rrterus  in  sagittal  section  showing  diffuse  adeno- myoma,  from  a  spinster 
32  years  of  age.  The  gland  s^Daces  were  cystic  and  filled  with  gelatinous 
material. 

A  rare  epithelial  change  in  the  endometrium  is  known 
as  papilloma  of  the  endometrium.  In  this  condition  the 
uterine  cavity  is  filled  with  villi  (Fig.  177).  Each  of  these 
has  a  delicate  axis  of  vascular  connective  tissue  covered 
with  a  single  layer  of  columnar  epithelium.  The  clinical 
signs  are  similar  to  those  caused  by  cancer  of  the  corporeal 
endometrium. 

Adeno-myoma. — This  term  is  applied  to  a  pathologic  con- 
dition of  the  uterus  the  leading  features  of  which  have  been 
admirably  summarized  by  Cullen  in  the  following  terms: 
"  It  is  diffuse  in  character,  situated  in  the  middle  layer  of 


376 


EPITHELIAL   TUMOURS 


the  uterine  wall,  and  is  dependent  on  the  uterine  mucosa 
for  its  glandular  elements."  Although  several  observers,  in- 
cluding von  Recklinghausen,  have  recorded  isolated  examples 
of  this  disease,  Cullen  seems  to  have  been  the  first  to  draw 
attention  to  its  clinical  importance  (1897). 

In  well-marked  cases  adeno-myoma  presents  clinical 
features  which  cause  it  to  resemble  the  common  varieties 
of  submucous  fibroids.  The  ages  of  the  patients  vary 
from  20  to  50  years  ;   the  uterus  is  usually  enlarged,  but  in 


Fig.  179. — Microscopic  features  of  diffuse  adeno-myoma  of  the  uterus.     X  60. 
{Frraik  E.  Taylor.) 

exceptional  instances  adeno-myoma  occurs  in  small  atrophic 
uteri.  Adeno-myomatous  changes  are  often  associated  with 
fibroids.  Small  bodies  under  the  serous  coat  of  these  uteri 
often  resemble  stalked  subserous  fibroids ;  they  are  really 
"  buds  "  of  adeno-myomatous  tissue. 

When  the  uterus  is  removed  and  divided  longitudinally, 
the  walls  are  seen  to  be  greatly  thickened,  measuring  in  some 
specimens  5  cm.  (2  in.)  in  thickness  ;  this  increase  is  due 
to  the  formation  of  new  tissue  between  the  outer  wall  of  the 
uterus  (the  subserous  stratum)  and  the  superficial  layer  of 
the  endometrium.  There  is  no  attempt  at  encapsulation, 
and  the  term  "diffuse"  is  thoroughly  justified.    (Fig.  178.) 


ADENO-MYOMA   OF   TEE   UTERUS 


377 


The  cut  surface  of  the  adventitious  tissue  differs  from  that 
presented  by  the  common  hard  fibroid  in  another  particular, 
for,  instead  of  forming  the  well-known  vortex  arrangement, 
the  muscular  tissue  is  disposed  in  an  irregular  manner,  and 
on  the  freshly  cut  surface  it  produces  a  pattern  not  unlike 
that  of  the  fabric  known  as  "  watered  silk." 

The  new  tissue  consists  mainly  of  bundles  of  plain  muscle- 
fibre,  which,  instead  of  being  arranged  in  vortices,  as  is  so 


Fig.  180. — Uterus  in  section  showing  diffuse  adeno-myomatous  disease.     The  poly- 
poid process  contains  glandular  elements.     From  a  spinster  aged  43  years. 

common  in  the  ordinary  hard  fibroid,  are  disposed  in  an 
irregular  manner,  and  the  spaces  between  the  bundles  are 
filled  with  the  peculiar  stroma  of  the  uterine  mucosa, 
containing  gland-tubules  lined  with  columnar  epithelium  of 
the  same  type  as  the  normal  tubular  glands  of  the  endo- 
metrium. The  glandular  elements  appear  to  be  uniformly 
distributed  throughout  the  adventitious  tissue,  and  can  be 
detected  up  to  the  limits  of  the  thin  muscular  stratum 
underlying  the  peritoneal  coat  of  the  uterus.  The  amount 
of  glandular  tissue  varies  greatly  in  different  cases.    (Fig.  180.) 


378 


EPITHELIAL   TUMOURS 


An  interesting  featnre  of  the  disease  is  the  frequency 
with  which  uteri,  the  seat  of  this  change,  afford  evidence  of 
antecedent  inflammation.  The  Fallopian  tubes  are  frequently 
thickened  and  their  ccelomic  ostia  occluded ;  the  uterus  is 
in  many  cases  firmly  adherent  to  the  bladder  and  intestines. 

It  is  quite  possible  that  adeno-myoma  of  the  uterus  is  due 
to  a  micro-organism,  for  several  specimens  have  been  de- 
scribed, in  which  uteri,  the  seat  of  this  change,  have  also  been 


Fig.  181. — Uterus  laid  open  by  a  vertical  incision.  The  endometrium  on  the 
anterior  waU  is  occupied  by  an  unencapsuled  mass  of  tuberculous  adenomatous 
tissue.  From  a  spinster  aged  46  years.  The  patient  was  in  excellent  health 
four  years  after  the  operation. 

tuberculous.  The  symptoms  produced,  by  such  complex 
changes  are  like  those  which  accompany  a  degenerating  sub- 
mucous fibroid.  Specimens  of  this  kind,  have  been  described 
by  Archambault  and  Pearce  in  New  York,  by  Grlinbaum  in 
Berlin,  and  by  myself  in  London. 

Clinically,  adeno-myoma  of  the  uterus  is  liable  to  be  mis- 
taken for  submucous  or  interstitial  fibroids.  After  operation 
it  requires  the  use  of  a  microscope  for  identification;  even 
then  many  specimens  have  been  mistaken  for  cancer  of 
the  corporeal  endometrium. 


ADENO-MYOMA    OF  THE   UTERUS  379 

The  leading  clinical  features  may  be  summarized  thus  : 
Excessive  menorrhagia  and  profound  anaemia  in  women 
between  the  twentieth  and  fiftieth  years,  usually  accompanied 
by  an  enlargement  of  the  uterus  like  that  which  is  caused 
by  a  submucous  fibroid.  Diffuse  adeno-myoma  of  the  uterus 
occurs  in  spinsters  and  in  barren  married  women  as  well  as 
in  those  who  are  fertile.  In  forty-nine  cases  examined  by 
CuUen,  "  nine  patients  were  spinsters  and  forty  were  married ; 
of  these  six  were  sterile,  two  had  had  miscarriages,  and 
thirty-two  had  had  children."  Among  the  sixteen  cases 
observed  by  Grlinbaum,  six  had  borne  children.  Of  the 
fifteen  cases  under  my  own  care,  seven  of  the  patients  were 
spinsters,  and  of  the  eight  married  women-  four  were  mothers 
and  one  had  been  delivered  of  fourteen  living  children. 

Treatment. — When  the  patient's  health   is   undermined 
from  the  prolonged  and  excessive  bleeding  which  is  associated 
with  this  disease,  the  uterus  should  be  removed.     Vaginal  as 
well  as  abdominal  hysterectomy  gives  excellent  results,  im 
mediate  and  remote. 

Archambault,  J.  L.,  and  Pearce,  R.  M.,  "  Taberculose  d'un  Adenomyome  de 

rUterus." — JRev.  de  Gyn.  et  de  Chir.  Abdom.,  1907,  xi.  3. 
Bland-Sutton,  J.,   "The   Position  of  Abdominal  Hysterectomy  in   London," 

1910. 
Cameron,  S.  J.  M.,  and  Taylor,  F.  E.,  "On  Adenomyoma  of  the  Uterus." — 

Journ.  of  Obstet:  and  Gijn.  of  Brit.  Emp.,  1904,  v.  248. 
Cullen,  T.  S.,  "Adenomyoma  of  the  Uterus,"  Philadelphia,  1908. 
Griinbaum,  D.,  "Adenomyoma   Corporis   Uteri   mit   Tuberculose. " — AreJi.  f. 

Gyn.,  1907,  Ixxxi.  383. 
Griinbaum,  D.,  "Clinical  Features   of  Adenomyoma." — Milncli.  med.   Woch., 

1908,  p.  1156. 

Lockyer,  C,  "Three  Cases  of  Adenomyoma  Uteri." — Trans.  Obstet.  Soc,  1906 
slviii.  84. 

Tate,  W.  W.  H.,  "  Two  Cases  of  Diffuse  Adenomyoma  of  the  Uterus." — Trans. 
Obstet.  Soc,  xlvi.  141. 


CHAPTER    XXXYII 

EPITHELIAL   TUMOURS  OF   THE   UTERUS 

(Continued) 

CARCINOMA  OF  THE  NECK  AND  BODY  OF  THE  UTERUS 

Carcinoma  of  the  neck  of  the  uterus. — This  part  of  the 
uterus  is  liable  to  both  squamous-celled  and  columnar- celled 
cancer,  according  to  the  situation  in  which  it  arises.     When 


^/■ft^^'^i^^— ^-r^^Si^^^^ 


Fig.  182. — Microscopic  characters  of  the  epithelium  covering  the  vaginal 
aspect  of  the  neck  of  the  uterus. 

the  disease  begins  on  the  vaginal  aspect  of  the  neck  of  the 
uterus,  it  is  of  the  squamous-celled  species  ;  if  its  origin  is  in 
the  cervical  endometrium,  the  cells  will  be  columnar  (Figs. 
182  and  183). 

A  large  amount  of  energy  has  been  devoted  to  the  micro- 
scopic examination  of  cancer  of  the  neck  of  the  uterus,  in  the 
hope  of  determining  the  relative  h-equency  of  the  squamous- 
celled  and  of  the  columnar-celled  variety.  So  far  as  my 
own  efforts  are  concerned,  they  were  directed  with  the  object 
of  deciding,  if  possible,  which  variety  gave  the  best  results  to 

380 


GANGER  OF   THE   UTERUS 


381 


operation  ;  but  after  a  long  and  laborious  investigation  I  came 
to  the  conclusion  that  it  was  hazardous  to  attempt  a  prediction 
simply  on  the  cell-features  of  the  cancer. 

Although  the  ultimate  results  of  cancer  arising  in  the 
cervical  endometrium,  or  on  the  vaginal  aspect  of  the  cervix, 
are  the  same,  it  will  be  advisable  to  discuss  their  pathologic 


Fig.  183. — Microscopic  characters  of  a  gland  from  the  cervical  endometrium. 

features  separately.  In  the  majority  of  patients  who  come 
under  observation,  particularly  in  hospital  practice,  the  disease 
has  already  destroyed,  or  eroded,  the  neck  of  the  uterus  to 
such  an  extent  that  it  is  impossible  to  determine  whether  it 
arose  in  the  cervical  canal  or  on  the  vaginal  surface ;  neverthe- 
less, patients  do  occasionally  come  under  observation  at  a 
sufficiently  early  stage  to  enable  an  exact  localization  of  the 


382 


EPITHELIAL   TUMOURS 


primary  focus  of  the  disease  to  be  made.  It  may  appear  as 
a  circular  ulcer  "witli  raised  and  everted  edges,  or  it  erodes 
the  tissues  deejDly  at  the  outset ;  exceptionally  it  forms 
luxuriant  warty  excrescences.  The  cancer  infiltrates  the 
cervix,  extends  to  and  implicates  the  vaginal  wall,  and 
involves  the  tissues  of  the  mesometrium.  Cancer  also  arises 
in  the  epithelium  in  any  part  of  the  cervical  canal  or  its 
glands,  but  it  aj)pears  to  be  more  prone  to  arise  in  the  lower 


Fig.  184. — Microscopic  characters  of  cancer  of  tlie  cervix. 

than  in  the  upper  half  of  the  canal.  It  begins  either  as  a 
deeply  eroding  ulcer,  or  as  a  soft,  fungating,  vascular,  cauli- 
flower-like outgrowth.  Commonly  the  cancer,  after  infiltrating 
the  adjacent  tissues  of  the  cervix,  spreads  into  the  meso- 
metrium and  imj)licates  the  vaginal  waU.  It  ulcerates  early, 
and  destroys  the  cervix  and  spreads  into  the  body  of  the 
uterus,  and  in  the  late  stages  this  organ  may  become  hoUowed 
out  by  ulceration  until  nothing  remains  but  a  thin  layer 
of  muscle-tissue  covered  by  peritoneum.  When  a  uterus 
hoUowed  out  in  this  way  has  its   cervical  canal  obstructed 


C ANGER   OF  THE    UTERUS 


383 


by  cancer,  tlie  uterine  cavity  becomes  distended  with  pus. 
This  condition  is  known  as  iiyometra.  The  pus  sometimes 
escapes  intermittently. 

The  microscopic  features  of  cancer  arising  in  the  cervical 
epithelium  consist  of  round  spaces  filled  with  columnar  epi- 
thelium. This  depends  on  the  fact  that  the  invasion  of  the 
tissues  is  due   to  columns  of  epithelium,  and  in  the  micro- 


Inflltrated  ovary. 


Uterine  cavity. 


Wall  of  bladder.  - 


Cancer. 


Cervical  canal. 


Vagina. 


Fig.  185. — Cancerous  uterus  in  sagittal  section. 

scopic  sections  these  cell-columns  are  represented  cut  at 
right  angles  (Fig.  ]84). 

Cancer  of  the  cervix  leads  to  infection  of  the  lumbar 
lymph-glands.  Dissemination  is  also  frequent,  and  secondary 
deposits  form  in  the  lung,  liver,  and  occasionally  in  the  bones, 
but  not  with  the  same  frequency  as  in  cancer  of  the  breast. 
Cancer  of  the  cervix  leads  to  perforation  of  the  anterior  and 
posterior  vaginal  septa,  so  that  urinary  and  fsecal  fistulas  are 
apt  to  complicate  the  late  stages  of  the  disease  (Fig.  186). 

When  the  broad  ligaments  are  extensively  infiltrated  the 


384 


EPITHELIAL   TUMOURS 


ureters  become  involved  ;  this  leads  to  dilatation  of  the  renal 
pelves.  Cystitis  is  a  common  complication  of  carcinoma  of 
the  cervix,  and  causes  suppurative  pyelitis  and  nephritis.  A 
very  large  proportion  of  patients  affected  with  cancer  of  the 
uterus  exhibit  marked  ursemic  symptoms  in  the  later  stages 
of  their  lives. 

Among  other  complications  of  cancer  of  the  cervix,  espe- 


Fig.  186. — Pelvis  and  its  viscera  in  section.     From  a  case  of  cancer  of  the  uterine 
cervix  which  invaded  the  bladder. 

cially  when  it  extends  to  the  body  of  the  uterus,  must  be 
mentioned  pyosalpinx  and  hydrosalpinx.  In  these  cases  the 
dilated  tubes  are  rarely  thicker  than  the  thumb,  but  they  are 
a  source  of  danger,  inasmuch  as  perforation  occasionally 
occurs  and  sets  up  infective  peritonitis.  Exceptionally  the 
cancer  perforates  the  body  of  the  uterus.  When  this  happens 
peritonitis   may   ensue   and   quickly   cause  death;    in   some 


GANGER   OF   THE    UTERUS 


385 


instances  tlie  carcinomatous  material  becomes  distributed 
over  the  peritoneum,  and  small  knots  form  upon  tbe  serous 
surfaces  of  the  intestine,  liver,  spleen,  etc.  This  distribution 
of  the  cancer  may  lead  to  an  effusion  of  blood-stained  fluid 
into  the  belly,  sometimes  in  considerable  quantity;  or  to 
agglutination  of  coils  of  intestine,  each  cancerous  nodule 
being  the  focus  of  a  limited  area  of  peritonitis.     Occasionally 


A/i'^<^" 


Fig.  187. — Cancerous  uterus  ia  coronal  section.  It  was  difficult  to  decide  whether 
the  cancer  began  in  the  upper  part  of  the  cervix  or  in  the  lower  part  of  the  body 
of  the  uterus.  A  process  of  the  growth  is  creeping  into  the  right  Fallopian  tube. 

actual  perforation  of  the  uterus  is  prevented  by  a  piece  of 
intestine  becoming  adherent  to  the  uterus  at  the  spot  where 
the  disease  is  approaching  the  surface :  adhesion  in  this  way 
rnay  take  place  between  the  uterus  and  the  small  intestine. 

It  is  important  to  bear  this  in  mind,  because  when  a  fgecal 
fistula  complicates  cancer  of  the  uterus  it  is  usually  attributed 
to  a  communication  with  the  rectum  or  sigmoid  flexure,  and 
these  are  the  common  situations;  but  in  some  cases  the 
fistula  is  in  the  transverse  colon,  for  when  this  section  of 
z 


386  EPITHELIAL   TUMOURS 

tlie  large  bowel  is  omega  shaped  the  lower  segment  of  the  loop 
often  comes  in  contact  with  the  fundus  of  the  uterus. 

Cancer  of  the  cervix  uteri  is  very  common  between  the 
ages  of  40  and  50 ;  many  cases  occur  between  30  and  40. 
Before  the  age  of  30  the  disease  is  rare,  but  I  have  observed 
undoubted  cases  in  women  of  23,  25,  and  26  years  of  age 
It  belongs  especially  to  the  latter  part  of  the  child-bearing 
period  of  life ;  it  is  almost  exclusively  confined  to  women 
who  have  been  pi^egnaAit  Critical  inquiry  shows  that 
injury  associated  with  coition  and  child-birth,  but  more 
particularly  the  latter,  is  a  potent  factor  in  producing  the 
changes  which  render  the  epithelium  in  this  situation  liable 
to  cancer,  and  it  is  disappointing  to  find  that  fecundity  in- 
creases this  liability. 

A  remarkable  record  bearing  on  this  matter  has  been 
published  by  Czerwenka.  A  woman  35  years  of  age  had  a 
double  vagina  and  uterus  bicornis  bicollis.  Coitus  was  practised 
in  the  left  vagina.  The  left  cervix  was  cancerous,  the  left 
uterus  contained  two  fibroids,  and  the  corresponding  Fallopian 
tube  contained  pus  and  had  its  coelomic  ostium  occluded. 

The  signs  of  cancer  of  the  cervix  are  bleeding,  offensive 
discharges,  and  sometimes  pain.  The  first  two  signs  are  those 
which  usually  lead  women  to  seek  advice. 

In  the  early  stages  the  margins  of  the  os  will  be  found 
everted,  and  a  fungous  mass  protrudes  from  the  canal,  which 
bleeds  on  the  slightest  touch.  In  the  late  stages,  when  the 
neck  of  the  uterus  is  destroyed  and  replaced  by  an  ulcerat- 
ing cancerous  mass,  there  is  no  difficulty  in  recognizing  the 
nature  of  the  lesion. 

Cancer  of  the  uterus  terminates  in  a  variety  of  ways : — 

1.  The  uterine  artery  may  be  opened  by  ulceration,  and 
fatal  hsemorrhage  ensue. 

2.  Repeated  bleeding  due  to  smaller  arteries  being  eroded 
will  often  lead  to  exhaustion  and  death. 

3.  Implication  of  the  bladder  and  one  or  both  ureters 
causes  cystitis,  septic  pyelitis,  and  uraemia.  Some  observers 
fix  the  frequency  of  renal  complications  in  this  disease  as 
high  as  70  per  cent. 

4.  Septic  changes  in  the  uterus  extend  to  the  Fallopiaii.- 
tube  an4  cf\,use  pyosalpinx. 


CANCER   OF  THE    UTERUS 


387 


5.  Peritonitis  may  be  caused  by  rupture  of  a  pus-containing 
Fallopian  tube. 

6.  Intestinal  obstruction  may  follow  adhesion  of  a  piece 
of  small  or  large  intestine  to  the  uterus,  or  direct  extension  of 
the  cancer  into  the  rectum. 

7.  Hydroperitoneum  and  hydrothorax  may  arise  from  the 
presence  of  secondary  nodules  of  cancer  on  the  peritoneum  or 
pleura. 

8.  The  cervical  canal  sometimes  becomes  occluded,  and  the 

Ovary  infiltrated  with  cancer. 


Fallopian  tube. 


Eound  ligament. 


Occluded  ureter. 


Cancer-mass. 


Vesical  orifice 
of  ureter. 


Fig.  188. — Cancer  of  the  neck  of  the  uterus  implicating  the  bladder  and  the  ureter. 


cavity  of  the  uterus  becomes  distended  with  pus  (pyometra). 
The  chief  danger  in  this  complication  is  due  to  the  Fallopian 
tubes  becoming  secondarily  distended  with  pus,  which  occa- 
sionally leaks  into  the  peritoneum,  with  lethal  results. 

Cancer  of  the  cervix  is  sometimes  complicated  with  other 
lesions  of  the  genital  organs,  such  as  ovarian  cysts  and 
tumours,  fibroids,  etc. 


388  EPITHELIAL   TUMOURS 

Treatment. — The  only  treatment  available  for  cancer  of 
the  neck  of  the  uterus  is  early  removal  of  the  whole  uterus. 
This  is  only  practicable  in  a  small  percentage  of  patients, 
because  the  disease  arises  and  spreads  so  insidiously  that  the 
cancer,  in  the  majority  of  cases,  has  overrun  adjacent  parts, 
such  as  the  vagina,  bladder,  rectum,  and  vesical  segments  of  the 
ureter ;  this  precludes  operative  interference.  In  recent  years 
methods  have  been  introduced  by  Ries,  Mackenrodt,  Duhrssen, 
and  Wertheim  which  enable  the  surgeon  to  remove  not  only 
the  uterus  and  its  neck,  but  the  broad  ligaments,  Fallopian 
tubes,  lymph-nodes  and  para-uterine  connective  tissue.  These 
very  extensive  operations  are  attended  with  a  high  mortality. 

Palliative  treatment. — In  many  cases  where  no  operation  is 
possible,  much  may  be  done  to  make  the  patients  comfortable. 
Careful  nursing  keeps  them  clean,  free  from  bed-sores  and 
fetor ;  a  difficult  matter  when  a  woman  has  a  faecal  or  a 
urinary  fistula,  or  both.  Pain  may  be  alleviated  by  phen- 
acetin  or  the  judicious  use  of  morphia. 

Carcinoma  of  the  cervix  and  pregnancy. — It  may  be  stated 
without  fear  of  contradiction  that  the  most  appalling  com- 
plication of  pregnancy  is  cancer  of  the  cervix.  It  is  some- 
what difficult  to  understand  how  a  woman  with  cancer  of  the 
neck  of  the  uterus  can  conceive,  but  it  is  quite  certain  that  it 
happens,  and  that  the  complication  is  not  uncommon.  How- 
ever, cases  in  which  cancer  in  this  situation  obstructs  delivery 
are  unusual,  and  this  is  due  to  two  circumstances : 

1.  Cancer  of  the  neck  of  the  uterus  predisj^oses  to 

abortion. 

2.  When  it  has  advanced  to  such  a  stage  as  to  fill  the 

vagina  with  an  obstructive  mass,  the  disease  has 
such  an  effect  upon   the   health   of  the   mother 
that  the  life  of  the  foetus  is  imperilled. 
The  second  condition  is  of  importance,  because  in  con- 
sidering the  advisability  of  Csesarean  section  in  these  circum- 
stances  it   is   well   to   be   satisfied  that   the  foetus  is  alive. 
However,  in  very  exceptional  cases  it  has  been  found  necessary 
to  resort  to  this  operation  in  order  to   deliver  a  dead  and 
putrid  foetus. 

The  careful  study  of  the  literature  relating  to  this  compli- 
cation shows  clearly  enough   that  when  a   pregnant  woman 


GANGER   OF  THE  UTERUS  389 

with  recent  cancer  of  the  uterus  comes  under  observation  in 
the  early  months,  her  best  hope  Hes  in  vaginal  hysterectomy. 
In  the  later  stages  (fourth  to  the  seventh  month)  very  good 
consequences  have  followed  amputation  of  the  cervix,  and 
this  operation  has  been  successfully  performed  without  dis- 
turbing the  pregnancy.  In  the  latest  stages  the  best  conse- 
quences have  followed  the  induction  of  labour  and  the 
immediate  performance  of  vaginal  hysterectomy — for,  surpris- 
ing as  it  may  seem,  the  uterus  enlarged  by  the  pregnancy  can 
be  safely  extirpated  through  the  vagina. 

These  methods  of  treatment  only  apply  to  cases  where  the 
cancer  is  in  such  a  condition  as  to  afford  reasonable  hope  of  a 
prolongation  of  life.  When  the  disease  is  in  an  inoperable 
stage  and  the  foetus  is  dead,  then  after  a  little  patient  waiting 
abortion  usually  occurs.  Where  there  is  reliable  evidence  that 
the  foetus  is  alive,  the  pregnancy  should  be  allowed  to  go 
to  term ;  if  the  cancer  affords  an  impassable  barrier  to  the 
transit  of  the  child,  then  Ctesarean  section  becomes  a  necessity. 

Cancer  of  the  body  of  the  uterus. — This  is  much  less  fre- 
quent than  cancer  of  the  neck  of  the  uterus.  It  arises  in  the 
epithelium  lining  the  uterine  cavity.  There  is  very  little 
accurate  knowledge  regarding  its  early  stages,  and  the  writer 
has  had  only  one  opportunity  of  obtaining  a  cancerous  uterus 
before  the  disease  had  extended  to  the  muscular  wall.  The 
disease  remains  for  a  long  time  restricted  to  the  body  of  the 
uterus,  and  may  creep  into  the  uterine  sections  of  one  or 
both  Fallopian  tubes ;  it  rarely  invades  the  cervix,  and  then 
only  in  the  late  stages  of  the  disease.  It  is  apt  to  perforate 
the  wall  of  the  uterus  and  infect  the  peritoneum  (Fig.  189). 

It  is  only  during  the  last  fifteen  years  that  the  importance  of 
cancer  of  the  body  of  the  uterus  has  been  clearly  appreciated. 
This  was  due  to  the  fact  that  there  were  no  means  available 
for  the  proper  examination  of  the  interior  of  the  organ,  and 
as  a  result  the  descriptions  of  diseases  of  the  endometrium 
were  disfigured  or  obscured  by  a  crowd  of  terms  such  as  senile 
endometritis,  malignant  endometritis,  villous  endometritis, 
and  so  on.  When  the  plan  of  mechanically  dilating  the 
cervical  canal  was  introduced,  so  that  the  endometrium  could 
be  examined  and  fragments  obtained  for  the  laboratory,  then 
light  began  to  shine,  and  we  obtained  some  accurate  data. 


390 


EPITHELIAL   TUMOURS 


As  in  other  organs,  cancer  of  the  body  of  the  uterus 
consists  of  cell-cohimns,  the  cells  beino-  identical  with  the 
epithelial  cells  of  the  endometrium.  The  disease  assumes  two 
distinct  forms .  Thus  it  may  appear  as  an  eroding  ulcer  pene- 
trating the  muscular  wall  of  the  uterus,  and  sometimes  even 
perforating  the  serous  coat  (Fig.  189).  In  the  common  form 
it  gives  rise  to  luxuriant  masses  of  soft,  succulent,  and  vascular 
polypus-masses  projecting  into  the  cavit}^  of  the  uterus  (Fig. 
190)  ;  this  is  the  variety  which  used  to  be  termed  villous 
endometritis. 


Fig.  189. — Cancerous  uterus  in  sagittal  section.  A  bud-like  process  of  cancer  has 
eroded  the  uterine  wall  and  protrudes  oa  the  peritoneal  sm-face.  The  peri- 
toneum was  dotted  with  thousands  of  secondary  nodules. 


As  the  diagnosis  of  cancer  of  the  body  of  the  uterus  is 
largely  determined  with  the  assistance  of  the  microscope,  it  is 
essential  for  those  who  venture  to  give  opinions  on  this  point 
to  be  thoroughly  familiar  with  the  various  abnormalities  of 
the  corporeal  endometrium,  and  especially  those  which  are 
known  as  glandular  polypi. 

Although  in  writings  and  in  clinical  Avork  we  treat  very 
definitely  of  cancer  of  the  cervical  endometrium  and  cancer 
of  the  corporeal  endometrium,  it  is  well  to  understand  that 


GANG  Ell   OF  THE    UTERUS 


391 


cases  come  to  hand  in  which,  after  the  uterus  has  been 
removed,  it  is  extremely  difficult  on  examining  the  organ  to 
state  positively  whether  the  disease  arose  in  the  body  ot 
the  organ  or  in  the  upper  segment  of  the  cervical  canal 
(Fig.  187). 

Cancer  of  the  corporeal  endometrium  is  unusual  before 
the  forty-fifth  year ;  it  is  most  frequent  at  or  subsequent  to 
the  menopause.  The  majority  of  the  cases  occur  between  the 
fiftieth  and  seventieth  years.  A  large  'proportion  of  the 
patients  are  nulliparoi. 


Fig.  190. — Uterus  with  "tubular"  cancer,  shown  in  coronal  section  ;    the  patient 
was  41  years  of  age,  and  mother  of  one  chUd. 

The  patient's  attention  is  usually  attracted  by  fitful 
haemorrhages  after  the  menopause,  followed  by  profuse  and 
offensive  discharoes  which  are  often  blood-stained.  The 
uterus  on  examination  may  feel  scarcely  enlarged  ;  sometimes, 
however,  it  is  much  bigger  than  usual.  In  some  instances 
cancer  of  the  corporeal  endometrium  is  associated  with 
fibroids. 

Treatment. — Cancer  of  the  body  of  the  uterus  entails  com- 
plete removal  of  the  organ,  including  its  neck,  by  the  abdomi- 
nal route.     The  ovaries,  Fallopian  tubes,  and  broad  ligaments 


S92  BPtTHELIAL  TUMOURS 

are  removed  with  the  uterus.  If  the  lymph-nodes  of  the 
pelvis  are  enlarged  and  signs  of  dissemination  are  obvious  on 
the  peritoneum,  omentum,  or  intestines  it  is  useless  to  remove 
the  uterus. 

Hysterectomy  for  cancer  of  the .  body  of  the  uterus  is 
followed  by  better  consequences,  immediate  and  remote,  than 
when  this  operation  is  performed  for  carcinoma  of  the  cervix. 

Variations  in  malignancy. — Cancer  varies  widely  in  its 
malignancy  in  nearly  all  the  situations  in  which  it  grows. 
As  a  rule,  cancer  in  the  neck  of  the  uterus  runs  its  course 
more  rapidly  than  the  same  disease  inside  the  uterus.  This 
is  due  in  a  large  measure  to  accidental  circumstances,  espe- 
cially to  the  facility  Avith  which  cancerous  tissue  becomes 
septic.  Cancers  are  not  encapsuled,  and  grow,  as  a  rule,  on 
an  epithelial  surface  exposed  to  micro-organisms.  Cancers  of 
the  neck  of  the  uterus  become  septic  more  quickly  than 
those  within  the  uterus.  Observation  also  shows  that  cancer 
of  the  corporeal  endometrium  becomes  septic  more  quickly 
in  a  multiparous  than  in  a  barren  woman.  The  objective  sign 
of  sepsis  in  connexion  with  uterine  cancer  is  haemorrhage. 

The  infection  of  cancerous  organs  by  pyogenic  micro- 
organisms makes  the  labours  of  surgeons  comparable  with 
those  of  Sisyphus.  A  careful  study  of  the  results  published 
by  those  surgeons  who  are  making  earnest  and  praiseworthy 
efforts  to  relieve,  by  surgical  means,  women  suffering  from 
cancer  of  the  neck  of  the  uterus,  shows  that  it  is  not  the 
technical  difficulties  which  baffle,  but  the  difficulty  of  con- 
trolling the  sepsis.  It  is  this  which  accounts  for  the  high 
mortality  of  what  is  known  as  the  radical  operation  for  cancer 
of  the  cervix ;  and  among  the  various  micro-organisms  which 
lurk  in  cancerous  tissues  the  virulent  streptococcus  is  fre- 
quently found. 


CHAPTER  XXXVIII 

UTERINE    FIBROIDS    COMPLICATED    WITH 
CANCER   OF   THE    UTERUS 

Uterine  fibroids  are  very  common,  so  is  cancer  of  the  uterus, 
and,  as  the  maximum  of  frequency  in  relation  to  age  is 
very  nearly  the  same  in  the  two  diseases,  it  is  not  a  matter 
for  surprise  that  they  should'  often  co-exist.  Whether  the 
presence  of  fibroids  predisposes  the  uterus  to  cancer  is  doubt- 
ful ;  but  it  may.  The  subject  may  be  conveniently  considered 
under  two  headings  : — 

1.  Cancer  of  the  neck  of  the  uterus  co-existing  with 

fibroids. 

2.  Cancer   of  the   body   of  the    uterus    complicating 

fibroids. 

(Cancer  of  the  Fallopian  tubes  may  be  associated  with 
uterine  fibroids.     See  Chap,  xxxix.) 

The  subject  is  an  important  one,  not  only  as  regards 
treatment,  but  also  from  the  diagnostic  point  of  view. 

1.  Cancer  of  the  cervix  and  fibroids. — The  special  dan- 
ger of  this  combination  depends  on  the  fact  that  it  is  liable 
to  be  overlooked,  because  the  most  prominent  clinical  feature 
of  fibroids,  as  well  as  of  cancer  of  the  uterus,  is  bleeding. 
When  a  patient  with  uncomplicated  cancer  of  the  neck  of 
the  uterus  comes  under  observation,  the  disease  is  almost 
certainly  recognized ;  but  when  a  woman  known  to  have  a 
fibroid  in  her  uterus  complains  of  more  than  usual  bleeding- 
she  is  not  so  likely  to  be  made  the  subject  of  routine  exami- 
nation, hence  the  disease  remains  for  an  indefinite  time  unsus- 
pected and  therefore  undetected.  There  is  also  another  dan- 
ger: when  cancer  attacks  the  parts  around  the  mouth  of 
the  womb  its  detection  is  a  fairly  simple  act ;  but  there  is  a 
fair  proportion  of  cases  in  which  the  disease  begins  a  short 
distance  up  the  canal ;  such  are  easily  overlooked,  and  the 

393 


394  EPITHELIAL  TUMOURS 

higher  up  the  canal  the  disease  is  situated  the  more  probable 
is  the  chance  that  it  will  escape  detection,  so  that  if  the 
uterus  contains  fibroids  the  chances  are  very  great  that  the 
bleeding  will  be  attributed  to  them,  and  the  existence  of  cancer 
will  be  entirely  overlooked.  Anyone  who  follows  carefully  the 
published  accounts  of  hysterectomy  for  fibroids  of  the  uterus, 
or  has  had  a  wide  experience  of  the  operation,  will  learn  that 
a  surgeon  while  performing  subtotal  hysterectomy  examines 
the  cut  surface  after  he  has  detached  the  body  of  the  uterus 
from  the  cervix,  and  if  it  looks  suspicious,  and  he  realizes  that 
it  is  cancerous,  the  neck  of  the  uterus"  is  excised.  In  a  few  cases 
subtotal  hysterectomy  has  been  performed,  and  the  patient, 
after  recovering  from  the  operation,  has  had  recurrence  of 
the  bleeding,  and  consults  the  surgeon,  who  on  examination 
finds  that  he  overlooked  a  cancerous  cervix.  On  one  occa- 
sion I  performed  a  total  hysterectomy,  and  some  months 
later,  as  the  patient  complained  of  vaginal  haemorrhages,  I 
examined  her,  and  found  a  recurrent  cancerous  mass  occupy- 
ing the  vault  of  the  vagma.  The  parts  removed  at  the  opera- 
tion had  been  preserved ;  they  were  examined  and  a  cancer- 
ous ulceration  was  found  at  the  os  uteri.  Although  total 
hysterectomy  was  performed  as  a  primary  operation,  in  ignor- 
ance of  the  existence  of  cancer,  it  failed  to  exercise  any  in- 
fluence for  good  on  the  progress  of  the  disease. 

This  matter  may  be  summarized  thus :  It  is  by  no 
means  uncommon  for  a  woman  known  to  have  fibroids  in 
her  uterus  to  lead  a  tolerably  comfortable  life,  in  spite  of 
profuse  or  even  long-drawn-out  menstrual  periods.  Occasion- 
ally a  patient  of  this  kind  suddenly  experiences  a  marked  in- 
crease in  the  flow,  or  has  what  she  terms  a  "flooding,"  is 
alarmed,  and  seeks  advice.  Cases  of  this  kind  require  careful 
consideration,  for  this  alteration  in  the  syniptoms  may  indi- 
cate changes  in  the  fibroid,  or  the  supervention  of  cancer.  If 
the  patient  is  a  spinster,  or  married  but  barren,  there  may  be 
concurrent  cancer  of  the  body  of  the  uterus.  If  married  and 
fertile  the  co-existence  of  cancer  of  the  cervix  must  be  con- 
sidered, and  it  is  well  to  bear  in  mind  that  an  early  cancer 
a  short  distance  up  the  cervical  canal  will  give  rise  to 
bleeding  and  escape  detection  by  the  examining  finger. 

There   is   another   aspect   of  cancer  of  the  uterine  neck 


UTERINE   GANGER  AND  FIBROIDS  395 

which  must  receive  consideration.  It  has  been  shown  that 
when  the  body  of  the  uterus  has  been  removed  for  fibroids, 
an  operation  known  to  surgeons  as  subtotal  hysterectomy, 
carcinoma  has  occurred  in  the  cervical  stump  at  such  an  in- 
terval after  the  operation  as  to  make  it  certain  that  it  did 
not  exist  at  the  time  the  body  of  the  uterus  was  removed. 
Such  a  case  has  come  under  my  own  observation  ;  and  it  has 
been  suggested,  especially  by  Richelot,  that  it  occurs  with 
sufiicient  frequency  to  make  it  advisable,  in  operations  per- 
formed for  the  cure  of  fibroids,  to  remove  the  neck  completely 
with  the  body  of  the  uterus  (total  hysterectomy)  to  avoid 
such  a  sequel.  This  recommendation  appears  too  sw^eeping, 
especially  in  view  of  the  fact  that  even  complete  excision  of 
the  neck  of  the  uterus  is  not  a  safeguard  against  the  occur- 
rence of  cancer,  for  Quenu  has  reported  an  observation  in 
which  carcinoma  arose  in  the  vaginal  cicatrix  four  years  and 
a  half  after  total  extirpation  of  the  uterus  for  disease  of  the 
appendages. 

An  instructive  record  bearing  on  the  subject  of  uterine 
fibroids  and  cancer  has  been  published  by  Blacker.  A  woman 
aged  39  years,  with  a  large  uterine  fibroid,  was  submitted  to 
bilateral  oophorectomy,  and  the  uterus  shrank  into  the  pelvis. 
Eight  years  later,  carcinoma  attacked  the  neck  of  the  uterus 
and  destroyed  the  patient. 

I  have  had  a  similar  experience.  In  January,  1902,  I 
removed  from  the  uterus  of  a  woman  aged  47  a  submucous 
fibroid  by  the  abdominal  route;  a  right  pyosalpinx  was  re- 
moved at  the  same  time.  She  reported  herself  four  years 
later  with  extensive  cancer  of  the  uterus. 

2.  Cancer  of  the  body  of  the  uterus  complicating 
fibroids.— This  is  not  an  uncommon  combination.  Cancer  of 
the  corporeal  endometrium,  or,  as  it  is  more  commonly  called 
in  clinical  reports,  cancer  of  the  body  of  the  uterus,  is  most 
frequent  at  or  subsequently  to  the  menopause.  The  majority 
of  the  patients  are  between  the  fiftieth  and  seventieth  years : 
and  a  large  number  of  the  patients  are  spinsters  or  harren 
wives. 

When  a  woman  complains  of  irregular  uterine  bleeding 
after  the  menopause  an  examination  is,  as  a  rule,  promptly 
made,  and  efforts  are  particularly  directed  to  determine  the 


396 


EPITHELIAL    TUMOURS 


existence  or  non-existence  of  cancer.  Many  women  with 
fibroids  do  not  cease  to  menstruate,  or  at  least  to  suffer  from  a 
more  or  less  regular  loss  of  blood,  for  many  years  after  the 
normal  age  for  the  menopause.  When  cancer  of  the  body  of 
the  uterus  arises  in  such  a  patient  it  is  extremely  liable  to  be 
overlooked. 

When  a  woman  known  to  have  a   fibroid  in  her  uterus 


Fig.  191. — Uterus  in  section,  showing  primary  cancer  of  the  corporeal  endometrium 
associated  with  fibroids.     From  a  spinster  aged  59  years. 

attains  the  menopause  and  remains  free  from  a  monthly  loss 
for  a  few  years,  then  suddenly  begins  to  have  "issues  of 
blood,"  this  may  be  due  to  cancer  of  the  body  of  the  uterus, 
and  is  always  such  a  suspicious  circumstance  that  it  demands 
the  most  careful  examination. 

The  matter  may  be  put  in  an  aphoristic  form :  Whe^i  a 
woman  with  uterine  fibroids,  having  passed  the  menopause, 
hegins  to  have  irregular  profuse  uterine  hcem,orrhages,  it  is 


UTERINE  GANCER  AND  FIBROIDS  397 

extreviely  probable   that   she   has  cancer  of  the  body  of  the 
uterus. 

It  occasionally  happens  that  a  patient  with  fibroids  may 
attain  her  menopause  and  remain  free  from  losses  of  blood  ;  in 
a  few  years  the  fibroid  may  become  infected  and  bleeding 
occur  profusely  as  a  sequel. 

It  has  been  suggested,  especially  by  Piquand,  that  there 
are  reasons  for  believing  that  submucous  and  interstitial 
fibroids  may  predispose  to  cancer  of  the  corporeal  endome- 
trium, for  the  presence  of  fibroids  sets  up  chronic  metritis,, 
which  renders  the  endometrium  susceptible  to  malignant 
transformation.  Piquand  also  analysed  a  thousand  cases  of 
fibroids  of  the  uterus  and  found  cancer  of  the  corporeal  endo- 
metrium present  in  fifteen  ;  this  is  a  high  proportion.  This 
induced  me  to  examine  a  consecutive  series  of  five  hundred 
cases  in  which  I  had  removed  the  uterus  for  fibroids,  and 
I  found  this  unhappy  combination  in  eight  instances,  the 
nature  of  the  disease  in  each  case  being  verified  by  a  care- 
ful microscopic  examination.  All  the  patients  were  over  50 
years  of  age. 

It  is  premature  to  assert  that  interstitial  and  submucous 
fibroids  exert  such  a  malign  influence  as  to  predispose  the 
corporeal  endometrium  to  cancer  ;  but  it  may  be  true,  and  it  is 
therefore  important  to  make  observations  of  a  clinical  and 
pathological  kind,  as  well  as  a  statistical  inquiry,  so  that 
a  sound  judgment  may  be  formed. 


Blacker,  G.,  "  Uterus  with  Fibroids  and  Carcinoma  of  the  Cervix,"  etc. — Traits. 

Obstet.  Soc,  1896,  xxxvii.  213. 
Bland-Sutton,  J.,  "  Essays  on  Hysterectomy,"  1905,  p.  60 
Bland-Sutton,  J.,  "  Uterine  Fibroids  complicated  with  Cancer  of  the  Body 

of  the  Uterus." — Journ.  of  Obstet.  and  G^jn.  of  Brit.  Emp.,  1906,1.  1. 
Piquand,  "  Fibromes  et  Cancer  Uterins." — Ann.  de  Gyn.,  Sept.  1905. 
Quenu,  Rev.  de  Gyn.  et.  de  Chir.  Abdom.,  Sept. -Oct.  1905. 

Turner,  G.  Grey,  "  Cancer  of  the  Cervix  and  Fibroids." — Brit.  Mod.  Journ., 
1905,  ii.  953. 


CHAPTER   XXXIX 

PAPILLOMA    AND    CARCINOMA    OF   THE 
FALLOPIAN   TUBE 

Papilloma. — Epithelial  tumours  of  an  innocent  type  occur 
primarily  in  the  Fallopian  tube.  One  of  the  best-known  ex- 
amples is  that  recorded  by  Doran,  in  which  the  tube  was  filled 
with  dendritic  masses  covered  with  mucoid  fluid  (Fig.  192). 
The  ccelomic  ostium  of  the  tube  was  open,  and  fluid  exuded 
from  it  into  the  pelvis.  The  excrescences  grew  from  all 
parts  of  the  mucous  membrane  in  the  dilated  portion  of  the 


192. — Papilloma  of  the  Fallopian  tube.     {After  Boran.) 


tube.  Several  pedunculated  cysts  with  thin  walls  rise  from 
amidst  the  excrescences  and  contain  papillary  outgrowths. 
The  free  surfaces  of  the  outgrowths  are  covered  with  colum- 
nar epithelium.  Some  of  the  cells  bear  cilia.  The  stroma 
is  made  up  of  small  fusiform  connective-tissue  cells,  and  is 
poorly  supplied  with  blood-vessels. 

When  a  Fallopian  tube  is  stuffed  with  warts  and  the 
ccelomic  ostium  remains  open,  the  irritating  fluid  which  leaks 
into  the  pelvis  from  the  tube  causes  hydroperitoneum. 
Doran's   case   illustrates   this  fact.     A  woman  aged  50  was 

398 


GANGER   OF  THE   TUBE  399 

repeatedly  tapped  for  ascites  and  large  quantities  of  fluid  were 
withdrawn.  Eventually  a  tumour  was  detected  in  the  pelvis  ; 
on  removal  it  proved  to  be  a  Fallopian  tube  stuffed  with 
papillomatous  tissue.  The  patient  was  in  good  health 
twenty-three  years  later,  and  the  fluid  did  not  reaccumulate 
in  the  belly  after  the  operation. 

When  the  presence  of  warts  in  the  Fallopian  tube  is 
associated  Avith  an  occluded  ccelomic  ostium,  the  fluid  cannot 
leak  into  the  pelvis,  but  it  sometimes  finds  its  way  into  the 
uterine  cavity  and  escapes  by  the  vagina.  Sometimes  a  sero- 
sanguineous  fluid  escapes  in  this  way  in  large  quantity. 
Removal  of  the  papillomatous  tube  arrests  the  discharge. 
When  warts  grow  in  a  tube  with  an  occluded  ostium  and  the 
fluid  cannot  run  out  through  the  uterine  opening,  the  tube 
becomes  distended  into  a  large  banana-shaped  cyst,  and  con- 
tains chocolate-coloured  fluid.  In  such  conditions  the  warts, 
which  are  soft  and  dendritic,  grow  most  abundantly  from  that 
part  of  the  sac  which  corresponds  to  the  ampulla  of  the  tube. 
It  is  a  significant  fact  that  papillomatous  tubes  occur  almost 
exclusively  in  patients  with  a  history  of  chronic  salpingitis. 
The  faculty  possessed  by  gonorrhoea  for  producing  warts  is 
proverbial. 

Carcinoma. — Our  knowledge  of  carcinoma  of  the  tube 
dates  from  1888 :  now,  thanks  to  the  industry  of  Doran, 
records  of  one  hundred  cases  are  available  for  the  purpose 
of  guiding  surgeons  in  its  detection  and  treatment. 

In  its  leading  features  this  disease  simulates  cancer  of 
the  body  of  the  uterus  ;  it  is  most  common  at  and  for  a  few 
years  after  the  menopause.  The  chief  clinical  feature  is  an 
irregular  blood-stained  discharge  from  the  vagina.  Primary 
cancer  of  the  Fallopian  tube  occurs  in  women  who  have  had 
children  as  well  as  in  those  who  are  sterile.  In  the  greater 
proportion  of  patients  the  disease  is  unilateral. 

The  symptoms  of  this  disease  are  so  similar  to  those 
caused  by  primary  cancer  of  the  body  of  the  uterus,  that  the 
cervical  canal  has  been  dilated  for  diagnostic  purposes  and 
nothing  found  within  the  uterus,  but  a  swelling  in  the  pelvis 
on  one  side  of  the  uterus  has  led  to  a  correct  appreciation  of 
the  cause  of  the  patient's  trouble. 

Cancer  of  the  Fallopig-n  tube   sometimes   co-exists  with 


400 


EPITHELIAL    TUMOURS 


uterine  fibroids.  I  have  met  with  it  on  two  occasions 
(Figs.  193  and  194).  These  two  cases  are  interesting  in  regard 
to  the  efi'ects  of  treatment.  In  one  woman  the  mouth  of  the 
cancerous  tube  was  open,  and  in  the  course  of  the  operation 
soft  growth  was  seen  protruding  from  it  and  spreading  to  the 
rectum  and  adjacent  peritoneum.  I  removed  much  of  this 
soft  cancerous  material  and  performed  subtotal  hysterectomy. 


BEP  J  CAU  .DEL 


Fig.  193. — A,  Ampulla  of  a  Fallopian  tube  occupied  by  a  primary  cancer  ;  B,  the 
ampuUa  of  the  tube  shown  in  section.  From  a  sterile  married  woman  57 
years  of  age.  The  growth  had  made  its  way  through  the  coelomic  ostium 
of  the  tube  and  infected  the  adjacent  peritoneum. 

The  patient  recovered  from  the  operation  and  enjoyed  good 
health  for  eleven  months  :  then  sims  of  recurrence  became 
manifest  in  the  pelvis,  and  she  died  a  few  weeks  later.  This 
case  illustrates  very  well  the  deadly  nature  of  the  disease. 
Examination  of  a  large  number  of  reports  testifies  that  after 
the  removal  of  a  cancerous  tube  the  disease  quickly  returns 
and  destroys  the  patient's  life.  It  has  been  suggested  that 
it  would  be  advantaofeous  to  remove  the  uterus  as  well  as  the 
Fallopian  tubes.     There  are,  however,  other  factors  to  be  con- 


GANGER   OF   THE   TUBE 


401 


sidered.  In  another  woman  with  primary  cancer  of  the  tube 
associated  with  uterine  fibroids  I  removed  the  uterus  as  well 
as  the  cancerous  tube.  In  this  instance  the  coelomic  ostium 
of  the  tube  was  completely  occluded  and  the  pelvic  peri- 
toneum remained  healthy.     The  patient  recovered  from  the 


CANCER 


Fig.  194. — Fallopian  tube  with  the  ovary,  mesosalpinx,  and  adjacent  portion 
of  the  wall  of  the  uterus.  The  ostium  of  the  tube  is  closed  and  the  ampulla 
distended  with  a  soft  cancerous  mass,  which  has  extended  along  the  lumen 
of  the  tube,  and  can  be  traced  in  its  tissues  in  its  course  through  the  uterine 
wall.  The  endometrium  was  not  implicated.  The  uterus  contained  several 
large  fibroids. 

operation,  and  reported  herself  in  good  health  three  years 
afterwards. 

This  specimen  is  of  great  interest,  for  it  appears  probable 
that  the  closure  of  the  coelomic  ostium  of  the  tube  when  its 
lumen  is  stuffed  with  cancerous  material  may  exercise  a  great 
influence  in  limiting  the  disease  to  the  tube  for  a  long  period, 
whilst  the  patency  of  this  orifice  will  favour  the  distribution 
of  the  cancer  within  the  abdomen. 

The  leakage  of  cancerous  material  from  the  tube  into  the 
pelvis  is  an  evil  thing,  especially  Avhen  an  ovarian  cyst  is 
present,  for  it  is  very  liable  to  become  infected  with  cancer 
2a 


402 


EPITHELIAL    TUMOURS 


and    the    condition    mistaken    for    primary   cancer   ot    the 
ovar}'. 

On  one  occasion,  when  remoTing  a  large  ovarian  cyst  from 
a  woman  52  years  of  age,  I  found  the  pelvic  section  of  the 
tumour  firmly  adherent  to  the  adjacent  tissues.  On  exam- 
ination of  the  tumour  after  removal,  the  Fallopian  tube 
connected  with  it  had  the  ampulla  stuffed  with  cancerous 


rig.  195. — Ovarian  cyst  infiltrated  witli  cancer  from  a  primary  focus  of  cancer 
in  the  ampulla  of  the  coiTesponding  Fallopian  tube. 

material.  The  ovarian  cyst  was  of  the  ordinary  multilocular 
type,  but  the  parts  in  relation  with  the  tube  were  infiltrated 
with  cancerous  tissue,  and  it  could  be  seen  easily  that  the 
thick  mass  on  the  cyst-wall  was  continuous  with  the  can- 
cerous material  within  the  tube.  The  appearance  presented 
by  the  parts  was  as  if  a  stream  of  cancer-particles  had  issued 
from  the  open  coelomic  mouth  of  the  tube  and  implanted 
themselves  on  the  wall  of  the  ovarian  cyst.  The  patient 
recovered  from  the  operation,  but  died  a  year  later  with 
generalized  cancer  of  the  abdomen. 


CANGEB   OF   THE    TUBE  403 

Glendining  made  an  interesting  observation  concerning 
the  spread  of  carcinoma  by  the  Fallopian  tube,  founded  on  a 
case  in  which  I  had  removed  two  ovarian  cysts  from  a  woman 
with  well-marked  cancer  of  the  stomach. 

The  cancerous  particles  had  infected  the  cysts,  and  on 
microscopic  examination  they  exhibited  the  characters  of 
implanted  cancer  (Chap.  Li.).  To  the  naked  eye  the  Fal- 
lopian tube  appeared  normal,  but  when  it  was  examined 
microscopically  cancer-particles  were  found  free  in  its  lumen  : 
the  subepithelial  and  plical  folds  were  extensively  infiltrated 
with  cancer. 

From  a  careful  consideration  of  the  matter,  Glendining 
came  to  the  not  unreasonable  conclusion  that  infection  of  the 
Fallopian  tube  was  brought  about  by  cancer-cells  swept  into 
it  throusrh  its  coelomic  ostium  and  ensfrafting'  themselves  on 
the  mucous  membrane,  subsequently  penetrating  to  the 
deeper  tissues. 

It  is  a  noteworthy  fact  that  bilateral  cancer  is  more 
common  in  connexion  with  the  Fallopian  tubes  than  in  any 
other  paired  organ  of  the  body.  This  supports  Glendining's 
view  that  many  cases  of  bilateral  cancer  of  these  tubes 
supposed  to  be  primary  are  really  secondary  to  a  focus  of 
cancer  in  some  part  of  the  gastro-intestinal  tract.  It  is  also 
equally  possible  that  a  primary  cancer  in  one  tube  infects  the 
opposite  tube  through  the  open  ostia. 

Treatment. — With  our  present  experience  it  is  justifiable 
to  treat  primary  cancer  of  the  Fallopian  tube  by  operation. 
In  order  to  give  the  patients  a  good  chance  the  tube  should 
be  removed  as  soon  as  the  disease  is  discovered,  and  whenever 
possible  the  uterus  should  be  removed  with  it. 

The  operative  risks  are  not  so  great  as  when  a  cancerous 
uterus  is  removed,  for  in  the  latter  case  the  organ  has  become 
septic  before  its  removal  is  attempted,  whereas  the  isolated 
position  of  the  Fallopian  tube  protects  it  from  the  invasion 
of  pathogenic  micro-organisms :  these  have  easy  access  to  a 
cancerous  endometrium,  especially  in  a  multiparous  woman. 

The  outlook  for  patients  with  primary  cancer  of  the 
Fallopian  tube  is  sad,  because  the  majority  of  these 
women  die  from  recurrence  of  the  disease  within  a  year  of 
operation. 


404  EPITHELIAL    TUMOUES 

Bland-Sutton,  J.,  "  On  Cancer  of  the  Ovary." — Brit.  Med.  Jonrn.,  1908,  i.  5. 

Bland-Sutton,  J.,  "  The  Clinical  Aspect  of  Secondary  Cancer  of  the  Ovary." — 
Clin.  JouTii.,  1910,  xxxvii.  104. 

Doran,  A.,  "  Papilloma  of  the  Fallopian  Tube,  associated  with  Ascites  and 
Pleuritic  Effusion."— Trares.  Path.  Soc,  1880,  xxxi.  174. 

Doran,  A.,  "A  Table  of  over  fifty  complete  Cases  of  Primary  Cancer  of 
the  Fallopian  Tube."' — Joxi,Tn.  of  Oistet.  and  6yn.  of  the  Brit.  Emjp.,  19C4, 
vi.  285. 

Doran,  A.,  "Primary  Cancer  of  the  Fallopian  Tube." — Ihid..  1910,  xvii.  1. 

Glendining,  B.,  "The  Spread  of  Carcinoma  by  the  Fallopian  Tube." — Arcli. 
of  Middx.  Hosp.,  xix.  82. 


GROUP  IV.    ENDOTHELIAL  TUMOURS 

CHAPTER   XL 
ENDOTHELIOMAS 

The  peculiar  flattened  cells  known  as  endothelium  which  line 
the  interior  of  blood-vessels  and  lymphatics,  and  cover  the 
surface  of  serous  membranes  such  as  the  pleura,  pericardium, 
and  peritoneum,  are  the  source  of  malignant  tumours  known 
as  endotheliomas.  In  their  general  characters  endotheliomas 
resemble  the  carcinomas  and  sarcomas,  but,  though  decidedly 
malignant,  they  run  a  slower  course  than  the  typical  sarcomas. 

Endotheliomas  which  arise  in  blood-vessels  are  termed 
hsemendotheliomas  ;  those  starting  from  lymph- vessels  are 
lymphendotheliomas.  There  is  also  a  variety  which  arises 
in  the  perivascular  lymphatics,  known  as  peritheliomas. 

Some  of  the  most  characteristic  examples  of  hsemendo- 
theliomas  may  be  regarded  as  malignant  angeiomas,  and  of 
lymphendotheliomas  as  malignant  lymphangeiomas. 

Some  of  the  best  examples  of  endotheliomas  grow  in 
connexion  with  the  gums,  where  they  resemble  in  their 
general  features  and  microscopic  structure  the  cystic 
epithelial  tumours  of  the  jaws  {see  p.  212). 

An  important  set  of  tumours  which  belongs  to  this 
group,  and  which  has  long  been  a  pathological  puzzle,  is  the 
so-called  sarcomas  of  the  salivary  glands,  especially  those 
which  grow  in  the  parotid  gland.  These  tumours  appear 
as  oval,  smooth,  elastic  swellings,  which  burrow  deeply  into 
the  gland,  dip  beneath  the  sterno-mastoid,  and  acquire 
attachments  to  the  sheath  of  the  carotid  artery  and  internal 
jugular  vein.  The  facial  nerve  is  usually  involved  in  large 
tumours  of  the  parotid,  and  is  liable  to  be  injured  when 
attempts  are  made  to  remove  them. 

405 


406 


ENDOTHELIAL   TUMOURS 


When  left  to  themselves  sucli  tumours  cause  death  in 
a  variety  of  ways.  Thus  they  may  press  upon  the  pharjaix 
and   lead  to  fatal  dysphagia,  or  ulceration  may  open   some 


A  V-..i,  Yin 
/ir'  ;r",  iii^iir 


iiim 

rf 


*  I. 


mM^m 

Hi 


Fig.  196. — ^Parotid  tiimour  whicli  had  been  slowly  growing  seventeen  years.  When 
the  woman  was  57  it  grew  rapidly  and  infected  the  lymph-glands,  and 
destroyed  the  patient  in  six  months. 


large  vessel  in  the  neck  and  produce  fatal  haemorrhage; 
secondaiy  nodules  sometimes  form  in  the  lungs,  and  induce 
fatal  broncho-pneumonia. 


ENDO  TEELIOMAS 


407 


Structurally,  these  tumours  exhibit  extraordinary  variety. 
Some  consist  entirely  of  hyalin  cartilage  arranged  in 
lobules  bound  together  by  loose  connective  tissue.  The 
cells  of  the  cartilage  rarely  possess  capsules,  and  are  often 
stellate,  as  in  immature  cartilage.  Such  tumours  otow  with 
extreme  slowness,  and  rarely  exceed  a  bantam's  egg  in  size ; 


Fig.  197.— Chondroma  of  the  submaxillary  glaud  which  had  been  slowly  growing 
forty-four  years.     It  was  successfully  removed. 

they  may  require  ten  or  even  twelve  years  to  attain  such 
proportions. 

The  large,  rapidly  growing  tumours  consist  of  spindle 
cells  in  which  tracts  and  islets  of  hyalin  cartilage  are  in- 
terspersed. When  chondral  tissue  is  abundant,  it  is  very 
prone  to  mucoid  changes,  and  soft,  fluctuating  spaces  are 
formed.  The  connective  tissue  is  very  liable  to  undergo 
myxomatous    change,  and,  as    if   to    render    these    tumours 


408 


ENDOTHELIAL    TUMOURS 


more  complex,  portions  of  the  secreting  tissue  of  the  gland 
are  imprisoned   in  them. 

It  is  not  unusual  in  sections  from  a  parotid  sarcoma 
to  meet  with  spindle  cells,  cartilage,  myxomatous  tissue, 
glandular  acini,  and  fibrous  tissue  in  an  area  of  2  cm. 
square.  Exceptionally,  transversely  striped  spindle  cells  are 
seen.  Parotid  tumours  of  such  complex  structure  grow 
rapidly   and   attain    a   large    size,    and    often    infiltrate  the 


Fig.  198. — Microscopic  appearances  of  a  hsemendothelioma  of  the  kidney. 
(After  Ziegler.) 

surrounding  tissue  and  skin.  Some  of  them  infect  the 
adjacent  lymph-glands  (Fig.  196)  and  give  rise  to  secondary 
deposits  in  the  lungs. 

Chondrifying  tumours  of  the  parotid  are  most  frequent 
between  the  fifteenth  and  thirty-fifth  years,  but  they  have 
been  observed  as  late  as  the  seventy-fourth  year.  In  their 
early  stages  they  are  easily  removed,  but  many  of  the  rapidly 
growing  forms  so  quickly  infiltrate  the  surrounding  parts  that 
their  complete  extirpation  is  not  always  possible. 

Endotheliomas  are  far  less  frequent  in  the  submaxillary 
than  in  the  parotid  gland  (Fig.  197).    They  are  encapsuled  and, 


ENDOTHELIOMAS 


409 


as  a  rule,  shell  out  easily.  They  grow  slowly,  and  occur  in 
the  young  as  well  as  in  adults.  Glandular  tissue  is  often 
associated  with  the  cartilage.  Similar  tumours  occur  in 
the  lachrymal  gland ;  they  are  extremely  rare  in  this  situa- 
tion. The  chief  features  of  endotheliomas  in  the  parotid 
gland   are   these :    a   tumour   will   arise   in   the   gland    and 


Pig.  199. — A  breast  in  section  ;   it  contains  an  endothelioma   (perithelioma) .     The 
nipple  is  unaffected. 

grow  to  the  size  of  a  walnut,  and  remain  stationary  ten, 
fifteen,  and  even  forty  years;  then  without  warning  it  enlarges, 
infiltrates  the  gland,  causes  pain,  and  destroys  life  in  a  few 
months. 

In  another  case  the  tumour  will  arise,  grow  quickly, 
ulcerate,  and  destroy  the  patient's  life  in  six  or  nine  months. 
The  microscopic  structure  of  the  tumours  is   similar. 

Endotheliomas    have    been   observed   in   the    mammary 


410 


ENDOTHELIAL    TUMOURS 


gland,  in  the  skin  (especially  in  association  witli  moles  and 
warts),  the  uterus,  and  the  omentum.  These  tumours  some- 
times present  clinical  characters  by  which  they  may  be 
recognized.  For  example,  a  woman  came  under  observation 
with  a  globular  tumour  in  her  breast.  She  stated  that  the 
tumour  had  been  growing  slowly  for  two  years.  The  skin 
covering  the  mass  was  smooth  and  not  infiltrated  b}''  growth, 
and  the  nipple  projected  normally.  The  axillary  lymph- 
nodes  were  enlarged.  The  characters  of  the  tumour  differed 
from  those  usually  presented  by  primary  mammar}"  cancer. 


Fig.  200.— Microscopic  characters  of  a  perithelioma,  showing  the  cell-mantle  around 
the  blood-vessels.    (After  Ziegler.) 

The  breast  was  amputated,  and  on  microscopic  examination 
the  tumour  proved  to  be  a  perithelioma  (Figs.  199  and  200). 

Peritheliomas. — This  variety  includes  the  rare  tumour 
styled  angeio-sarcoma  (Ziegler).  On  microscopic  examination 
the  tissues  of  such  tumours  resemble  superficially  the  lobes 
of  the  hver;  this  peculiarity  depends  on  an  overgrowth  of 
cells  in  the  perivascular  sheaths  of  the  small  vessels  (Fig.  200). 

Psammomas  (dura-endotheliomas). — This  variety  grows 
in  connexion  with  the  dura  and  the  pia  mater  of  the  brain 
and  spinal  cord.  These  tumours  are  called  psammomas,  or 
sand  tumours,  on  account  of  the  presence  in  varying  quantity 
of  earthy  matter  like  that  in  the  pineal  body.  Cholesterin 
is  also  present,  and  often  in  such  quantity  that  the  tumour 


PSAMM0MA8 


411 


assumes  a  pearly  lustre  when  exposed  to  light.  A  very 
remarkable  example  of  this  is  preserved  in  the  museum  of  the 
Royal  College  of  Surgeons,  London.  The  tumour,  which  fills 
the  fourth  ventricle,  has  an   average  diameter  of  10  cm.;   it 


Fig.  201. — Psammoma  lying  in  relation  with  the  flocculus.  The  patient,  a  man 
aged  36  years,  died  from  an  attempt  made  to  remove  the  tumoui'.  The  chief 
symptoms  were  deafness,  pain,  vomiting,  giddiness,  and  nystagmus. 

looks  like  a  solid  pearl  disparting  the  two  halves  of  the  cere- 
bellum, and  projects  between  the  inferior  vermiform  process 
and  the  medulla.  The  catalogue  contains  an  interesting 
clinical  history  furnished  by  Miss  B.  Knowles. 

A  psammoma  rarely  exceeds  in  size  a  shelled  walnut,  and 
when  growing  in  connexion  with  the  choroid  plexuses  of  the 


412  ENDOTHELIAL    TUMOURS 

cerebral  ventricles  these  tumours  may  be  bilateral ;  when  large 
they  form  deep  bays  in  the  adjacent  brain-tissue,  and  when 
growing  in  the  immediate  vicinity  of  important  nerves  cause 
severe  and  disastrous  consequences  (Fig.  201). 

The  structure  of  a  typical  psammoma  (Fig.  202)  shows  its 
intimate  relation  to  blood-vessel ;  each  concentric  body  has  a 
vessel  for  its  centre. 

A  common  place  for  a  psammoma  is  the  immediate  neigh- 
bourhood of  the  flocculus.  In  this  part  of  the  cranial  cavity 
they  are  often  bilateral,  and  for  many  years  I  have  believed 


i 


"^^N*^     //^w/ /'>-..>  W^^  " 


III' 


Fig.  202. — Microscoijical  appearance  of  a  typical  psammoma. 

that  in  this  situation  they  arise  from  the  processes  of  cho- 
rionic villi  belonging  to  the  fourth  ventricle  which  at  this 
spot  emerge  from  the  cornucopia. 

It  is  easy  to  understand  that  tumours  growing  in  close 
relation  with  such  important  nerves  as  the  trigeminal,  facial, 
vagus,  would  soon  lead  to  symptoms  and  surely  attract  at- 
tention, and,  as  a  matter  of  fact,  a  large  number  of  examples 
have  been  recorded  under  a  variety  of  names,  such  as  sar- 
comatous tumours  of  the  fifth  and  seventh  nerves ;  fibro- 
sarcomatous  tumours  of  the  flocculus ;  symmetrical  tumours 
of  the  medulla,  and  the  like. 

A  man  with  bilateral  tumours  of  this  kind  was  violent, 
blind,  deaf,  and  suicidal  (Strahan).     In  another  case  a  psam- 


PSAMMOMAS 


413 


moma  measuring  7'5  by  6  cm.,  growing  from  tlie  membranes 
immediately  covering  the  median  lobe  of  the  cerebellum  in 
a  lad,  caused  headache,  vomiting,  blindness,  optic  neuritis, 
priapism,  opisthotonos,  and  other  disturbances,  ending  in 
death  (Beevor). 

Psammomas  of  the   spiral   membranes   are    as    dangerous 
when  seated  high  in  the  spinal   canal  as  psammomas   near 


Pia  mater 


Fig.  203. — Portion  of  the  spinal  cord  with  a  psammoma  situated  at  the  level  of  the 
intervertebral  disc  between  the  tenth  and  eleventh  thoracic  vertebrse.  From  a 
woman  46  years  of  age.     {Museum,  Middlesex  Hospital.) 


the  flocculus.  In  the  spinal  canal  these  tumours  do  not 
attain  a  large  size — indeed,  in  the  few  recorded  cases  there  is 
singular  uniformity  in  their  shape  and  dimensions  (Fig.  203). 

Treatment. — Psammomas  of  the  spinal  membranes  have 
been  successfully  removed  by  surgeons.  In  the  cranial  cavity 
the  accurate  diagnosis  and  localization  of  such  tumours  has 
been  accomplished ;  they  have  also  been  removed,  even  when 
lying  in  the  vicinity  of  the  flocculus,  in  spite  of  their  sub- 
tentorial  situation,  but  rarely  with  success. 

Psammoma-bodies    are    fairly   common    in    the    choroid 


414  ENDOTHELIAL    TUMOURS 

plexuses  of  the  lateral  ventricles  of  horses.  When  the  tumours 
are  large  they  produce  grave  and  even  furious  symptoms.  In 
some  of  the  reported  cases,  horses  have  destroyed  themselves 
by  wild  plunges  made  in  attacks  of  delirium.  These  tumours 
are  very  vascular;  some  are  soft,  others  are  hard.  Nearly 
all  contain  cholesterin.  Probably  they  are  of  inflammatory 
origin. 

Beevor,  C.  E.,  "A  Case  of  Tumour  of  the  Cerebellum."— i?ram,  1881-2,  iv.  250. 

Nash,  W.  G.,  "  Primary  Sarcoma  of  the  Omentum." — Proc.  Roy.  Soc.  of  Med., 
Obstet.  Sec,  1909,  ii.  226. 

Strahan,  "  Symmetrical  Tumours  at  the  Base  of  the  Brain." — Journ,  Mental 
Sou,  1884,  xxix.  246. 


GROUP   V.    TUMOURS   ARISING   FROM 
THE    CHORIONIC  VILLI 

CHAPTER  XLI 
CHORION -EPITHELIOMA    (DECIDUOMA) 

In  1889  Sanger  and  Pfeiffer  independently  described  a  variety 
of  malignant  disease  arising  in  the  uterus  which  presented 
microscopic  characters  so  strongly  resembling  decidual  tissue 
that  the  disease  was  named  decidiioma  ')nalignum.  Sub- 
sequent investigations  by  other  observers  brought  to  light 
the  important  fact  that  this  remarkable  disease  is  very  liable 
to  arise  in  the  endometrium  within  a  few  weeks  or  months 
of  abortion,  or  of  delivery  at  term,  and  especially  after  the 
expulsion  of  the  so-called  "hydatid  mole."  Moreover,  the 
microscopic  investigation  of  the  tumour  showed  that  it 
conformed  in  histologic  type  to  the  multinuclear  mantle  or 
syncytium  which  covers  the  chorionic  villus.  This  discovery 
led  to  a  change  of  opinion  as  to  the  source  of  the  disease, 
and  as  most  writers  regard  it  as  arising  from  changes  in 
the  epithelial  elements  of  the  chorionic  villi  rather  than 
in  the  decidua,  the  name  chorion-epithelioma  has  come  to 
be  adopted  in  preference  to  deciduoma. 

Before  considering  the  essential  features  of  this  disease 
the  change  in  the  chorion  known  as  the  hydatid  mole  needs 
a  brief  description. 

The  normal  villi  of  the  chorion  in  the  early  stages  of  their 
development  consist  of  an  axis  or  core  of  delicate  connective 
tissue  covered  with  epithelium  arranged  in  two  layers:  the 
inner  is  known  as  Langhans  layer;  the  outer,  called  the 
syncytium,  is  peculiar,  and  resembles  a  large  elongated  multi- 
nucleated cell  enveloping  the  villus  like  a  mantle.  In  the 
early  stages,  the  connective-tissue  core  of  the  villus  is  devoid 
of  blood-vessels :  the  tissue  in  these  early  stages  consists  of 

415 


416 


OHOBION-EPITHELIOMA 


brandling  cells  separated  from  eacli  other  by  mucoid  inter- 
cellular substance ;  later,  the  cells  become  spindle-shaped  and 
the  tissue  denser  and  vascularized. 

In  the  disease  known  as  hydatid  mole  the  villi  become 
changed  into  transparent  grape-like  bodies  (Fig.  204),  and 
look  not  unlike  the  vesicles  so  characteristic  of  the  cystic 
stage  of  Tania  echinococcus  (hydatids),  and  a  hundred  years 
ago  the  grape-like  bodies  or  vesicular  bodies  were  regarded 
as  parasites,  especially  as  the  embryo  is  rarely  to  be  found  in 
these  specimens. 


Fig.  204.— Hydatid  mole.     (After  Bumm.) 

In  1827  Madame  Boivin  and  Velpeau  showed  that  the 
disease  depended  on  a  change  in  the  chorionic  villi.  Yirchow 
gave  attention  to  the  histology  of  these  vesicle-like  bodies, 
and  considered  them  to  be  due  to  a  myxomatous  change  in 
the  villi  (1853).  This  view  prevailed  until  Marchand  in  1895 
demonstrated  that  the  essential  feature  of  the  change 
depends  more  on  the  epithelium  than  on  the  stroma  of  the 
villus,  for  it  undergoes  irregular  proliferation  and  assumes 
invasive  characters,  penetrating  the  decidua  and  even  the 
muscular  wall  of  the  uterus.  The  vessels  of  the  villi  dis- 
appear, the  stroma  degenerates,  and  the  swollen  condition 
of  the  so-called  vesicles  is  the  result  of  cedema  rather  than  of 


HYDATID  HOLES 


417 


mucoid  change.  The  mvasiveness  or  destructiveness  of  these 
altered  villi  has  long  been  recognized,  and  specimens  have 
been  observed  in  which  the  villi  have  perforated  the  uterus 
and  caused  fatal  bleeding  into  the  abdominal  cavity. 

The  hydatid  mole  (or  chorion-ejnthelioma  benignum)  is 
not  common ;  it  has  been  estimated  by  one  writer  (Madame 
Boivin,  1827j  to  occur  once  in  20,000  pregnancies,  and  by 
another  (Williamson,  1899)  once  in  2,400.  It  is  quite  certain 
that  only  a  small  proportion  of  women  who  have  expelled 
hydatid  moles  suffer  from  chorion-epithelioma,  but  no  reliable 


Fig.  205. — Microscopic  appearance  of  a  chorionic  villus  from  a  hydatid  mole,  in 
transverse  section. 

estimates  are  available.  The  liability  of  a  woman  who  has 
had  a  miscarriage  of  this  kind,  to  be  the  victim  of  such 
a  deadly  disease  as  chorion-epithelioma  malignum,  renders 
it  advisable  that  she  should  keep  under  medical  supervision 
for  some  months  after  such  an  event. 

Some  writers  are  disposed  to  believe  that  there  are  two 
varieties  of  the  hydatidiform  mole,  one  being  purely  innocent, 
the  other  giving  rise  to  the  malignant  chorion-epithelioma. 
As  yet  microscopical  inquiries  have  not  provided  these 
theoretical  distinctions  with  a  histologic  foundation. 

Relation  of  the  hydatid  mole  (chorion-epitheliotna  benignum) 
to  lutein  cysts. — Some  valuable  observations  have  been  made 
2  B 


418 


GHOBION-EPITHELIOMA 


on  the  frequent  association  of  bilateral  lutein  cysts  of  the 
ovary  and  the  so-called  hydatid  mole ;  indeed,  the  presence 
of  lutein  cysts  in  this  disease  is  constant  enough  to  lead 
to  the  belief  that  the  two  conditions  are  correlated.  The 
lutein  cysts  are  large  enough  to  be  of  clinical  importance, 
and  they  have  been  known  to  obstruct  delivery  and  in  one 
instance  to  cause  acute  symptoms  by  undergoing  axial 
rotation. 

This  has  given  a  new  interest  to  the  yellow  tissue  which 
composes  the  greater  part  of  a  corpus  luteum,  and  some 
observers  state  that  it  furnishes  an  internal  secretion,  and  that 
the  adhesion  of  the  oosperm  to  the  endometrium  depends  on 
a  proper  supply  of  this  hypothetical  fluid. 


Fig.   206. — Portion  of  a  chorionic  villus  from  a  hydatid  mole  more  highly 
magnified  and  showing  a  piece  of  decidua. 


Fraenkel  has  elaborated  this  theory,  and  his  views  receive 
the  support  of  some  competent  German  pathologists  ;  an  over- 
production of  this  secretion,  the  result  of  a  plus  quantity  of 
lutein  tissue,  sets  up,  according  to  Pick,  a  "  chorion-epithe- 
liomatous  reaction  "  in  the  embedded  ovum  and  leads  to  the 
formation  of  a  benign  chorion-epithelioma  (hydatid  mole), 

Lockyer  has  made  a  careful  study  of  this  question,  and  the 
result  of  his  painstaking  inquiry  lends  great  support  to  the 
view  that  there  is  a  close  correlation  between  lutein  cysts  and 
chorion-epithelioma  of  both  kinds. 


GHOBION-EPI THELIOMA 


419 


Chorion  -  epithelioma  malignum  (deciduoma). — The  uterus 
when  attacked  by  this  disease  usually  enlarges  and  often 
becomes  big  enough  to  be  appreciable  as  a  tumour  in  the 
hypogastrium :  its  contour  may  be  nodular.  In  some  patients 
the  disease  is  limited  to  the  endometrium,  and  the  primary 
focus  of  the  disease  may  be  so  small  as  not  to  cause  enlarge- 
m.ent  of  the  uterus.  Some  very  exceptional  cases  have  been 
described  in  which  the  disease  did  not  involve  the  uterus,  but 
began  in  the  vagina. 


Fig.  207. — MiCioscopic  uhaiacteis  of  a  i.ell-maoo  fiom  a  cliOiioii-cpitLelioma  showing 
large  decidua-like  elements,  and  the  forms  intermediate  between  the  Langhans' 
layer  and  the  syncytium.     {After  John  H.  Teacher.) 

The  intimate  dependence  of  chorion-epithelioma  on  changes 
associated  with  pregnancy  is  illustrated  by  the  fact  that  the 
disease  occurs  primarily  in  the  Fallopian  tube  as  a  sequel  of 
tubal  pregnancy.     {8ee  Risel.) 

The  result  of  the  examination  of  a  large  number  of 
examples  of  this  disease  by  many  investigators  has  established 
the  fact  that  it  arises  in  portions  of  the  chorionic  villi  which 
remain  embedded  in  the  endometrium  after  the  expulsion  of 


420 


CHORION-EPITHELIOMA 


the  main  products  of  gestation,  and  especially  if  the  villi  have 
undergone  hydatidiform  change. 

Some  competent  authorities  still  believe  that  there  may 
be  two  varieties  of  this  disease,  one  arising  from  the  epithelial 
elements  of  the  chorionic  villi  and  the  other  in  decidual 
tissue. 

To  the  naked  eye  the  tumour-tissue  appears  on  section 
as  a  soft  reddish  mass.  "  Histologically  a  chorion-epithelioma 
consists  of  well-defiued   cells   of  various   shapes   and  sizes 


Fig.  208. — Portion  of  a  clioriouic  villus  from  a  chorion- epithelioma,  showing  the 
origin  of  the  tiunour  from  the  epithelium  of  the  villi.  {After  John  M. 
Teacher.) 

closely  packed  together,  and  large  multinuclear  irregular 
masses  of  protoplasm  in  which  no  definite  cell-masses  are 
recognizable.  This  tissue  invades  and  destroys  the  uterine 
tissues  after  the  manner  of  a  malignant  growth.  It  contains 
no  proper  connective-tissue  stroma,  or  blood-vessels  of  its 
own."     (Teacher.) 

A  remarkable  feature  connected  with  chorion- epithelioma 
is  the  discovery  that  some  teratomas  of  the  thorax 
and  of  the  testis  contain  tissue  indistinguishable  from 
that  of  chorion-epithelioma. 

The  eroding  power  of  the  cells  of  a  chorion-epithelioma 
enables  them  to  penetrate  the  tissues  and  gain  entrance  to 


CHOEION-EPITHELIOMA  421 

veins;  fragments  are  deported  by  the  blood-stream  to  lodge 
in  lungs,  bones,  and  other  viscera,  and  grow  into  fjecondary 
deposits.  The  common  situations  for  these  deposits  are  the 
lungs  and  vaginal  veins. 

The  course  of  the  disease  is  marked  by  oft-recurring  profuse 
bleeding  from  the  uterus ;  rigors ;  pyrexia ;  great  emaciation 
and  the  signs  of  dissemination,  such  as  secondary  nodules  in 
the  lungs,  bones,  and  the  abdominal  viscera.  The  disease  is 
fatal,  and  runs  usually  a  very  rapid  course,  but  it  exhibits 
remarkable  variations  in  virulence :  the  view  is  held  by  some 
observers  that  the  virulence  is  greater  after  an  abortion  than 
when  it  supervenes  on  a  pregnancy  which  has  run  to  term  or 
after  the  expulsion  of  a  hydatid  mole. 

The  chief  clinical  signs  are  frequent  bleeding  from  the 
uterus,  producing  great  an£emia,  and  accompanied  usually  by 
enlargement  of  the  uterus  following  a  recent  labour  or 
miscarriage.  Many  of  these  signs  are  caused  also  by  the 
retention  of  a  fragment  of  placenta,  or  a  uterine  mole.  In 
such  circumstances  the  cervical  canal  should  be  dilated  and 
the  cavity  of  the  uterus  explored  ;  any  retained  fragments  of 
conception  that  are  removed  should  be  submitted  to  careful 
microscopic  examination  in  order  to  establish  a  reliable 
diagnosis. 

Treatment. — The  most  satisfactory  method  of  dealing 
with  this  disease  is  prompt  removal  of  the  uterus.  Teacher 
considers  it  reasonable  to  conclude  that  operation  offers  a 
fair  chance  of  recovery,  and  that  it  may  be  done  with  some 
prospect  of  success  in  the  face  of  the  gravest  signs  of  disease 
and  even  if  metastasis  has  occurred. 

An  admirable  summary  of  knowledge  relating  to  lutein  cysts  and  their 
relation  to  chorion-epithelioma  (hydatid  mole)  is  given  by  Cuthbert 
Lockyer. — Joicrn.  of  Obstet.  and  Gyn.  of  Brit.  Emp.,  1905,  vii.  1. 

An  admirable  summary  relating  to  chorion  -  epithelioma  and  a  complete 
catalogue  of  the  literature  is  furnished  by  John  H.  Teacher. — Trans. 
Obstet.  Soc,  London,  1903,  xlv.  256. 

Risel,  "  Zur  Kenntniss  des  Primaren  Chorionepithelioms  der  Tube." — Zeitsclir. 
f.  Gcb.  unci  Gj/n.,  1905,  Ivi.  155. 


GROUP  VL    TERATOMAS  AND  DERMOIDS 

CHAPTER    XLII 
TERATOMAS 

In  this  group  we  have  to  consider  three  remarkable 
genera  of  tumours  which  in  their  type-forms  are  as  easily 
distinguished  as  a  butterfly  and  a  buttercup,  yet  examples 
occur  presenting  such  composite  characters  that  it  is  difficult 
to  assign  them  to  a  particular  genus.  The  difficulty  in  regard 
to  such  compound  tumours  as  teratomas  and  dermoids  occurs 
especially  in  relation  with  the  male  and  female  genital  glands. 
There  are  two  forms  of  teratomas,  external  and  internal.  This 
chapter  will  be  devoted  to  external  teratomas. 

A  teratoma  is  an  irregular  conglomerate  mass  containing 
the  tissues  and  fragments  of  viscera  belonging  to  a  sujypressecl 
fcetus  attached  to  an  otherivise  normal  individual. 

EXTERNAL   TERATOMAS 

In  order  to  appreciate  the  nature  ol  these  singular  mal- 
formations it  will  be  necessary  to  consider  the  subject  of  con- 
joined twins,  supernumerary  limbs,  and  acardiac  foetuses.  In 
the  animal  and  vegetable  kingdom  it  occasionally  happens 
that  a  single  ovum  gives  origin  to  two  embryos,  which  may 
be  quite  separate  from  each  other  (twins),  or  they  may  be 
united,  a  condition  known  as  conjoined  twins  (Fig.  209). 
When  twins  arise  from  a  single  ovum  they  are  said  to  be 
uniovular,  and  as  they  are  invariably  of  the  same  sex  they 
are  termed  homologous.  Conjoined  twins  are  always  homolo- 
gous and  uniovular. 

When  two  embryos  are  conjoined,  and  one  goes  on  to 
complete  development,  whilst  only  certain  parts  of  its  com- 
panion continue  to  grow,  the  result  is  a  parasitic  foetus.  The 
mature  individual  supporting  it  is  called  the  autosite. 

422 


CONJOINED  TWINS 


423 


In  other  examples  the  suppressed  foetus  consists  of  an 
irregular-shaped  tumour  growing,  perhaps,  from  the  posterior 
surface  of  the  sacrum,  or  within  the  abdomen  or  thorax, 
which  on  dissection  contains  a  fcAV  vertebroe,  or  processes  of 


Fig.  209. — The  conjoined  twin-sisters  Eadica  and  Doodica  at  the  age  of  3J  years; 
born  in  1889  at  Noapara,  a  village  in  the  province  of  Orissa,  India.  In  1899 
they  were  re-exhibited  in  London  in  excellent  health.  Doodica  died  in  1902 
{see  p.  432). 

skin  resembling  digits,  associated  with  a  piece  of  intestine 
or  an  imperfect  liver.     This  is  a  teratoma. 

In  order  to  demonstrate  the  relation  between  parasitic 
foetuses  and  teratomas,  it  will  be  useful  to  refer  to  dichotomy. 
In  animals  and  vegetables  there  is  a  strong  tendency  for 
parts  ending  in  free  extremities  to  bifurcate  or  dichoto- 
mize.    When  this  affects  digits  the  result  is  supernumerary 


424 


TERATOMAS 


fingers  and  toes.  Should  it  extend  to  the  axis  of  the  Hmb, 
supernumerary  legs,  wings,  or  fins  are  produced.  Dichotomy 
is  not  confined  to  the  limbs,  but  affects  also  the  axis  of  the 
trunk.  When  the  whole  embrj^onic  axis  dichotomizes,  twins 
are  produced.  Should  cleavage  be  partial,  and  affect  the 
caudal  end  of  the  trunk,  it  is  spoken  of  as  posterior  dicho- 
tomy. When  it  involves  the  anterior  end  it  is  called  anterior 
dichotomy.      With  complete  dichotomy,  in  which  both  era- 


Fig.  210. — Posterior  view  of  J._B.  clos  Santos  at  the  age  of  sixmonths.  {After  Acion.) 

bryos  go  on  to  full  development,  either  as  separate  or  con- 
joined twins,  we  are  not  further  concerned,  and  considera- 
tion of  the  conditions  arising  from  the  imperfect  growth  of 
one  embryo  whilst  its  companion  continues  to  develop  must 
be  deferred  until  we  have  discussed  the  results  of  partial 
dichotomy. 

Posterior  dichotomy. — When  cleavage  involves  the  caudal 
section  of  the  trunk-axis  to  any  serious  extent  it  necessarily 
follows  that  the  pelvis  as  well  as  the  vertebral  column  will 
be  reduplicated;  it  is  also  obvious  that  the  reduplication 
of  the  pelvis  involves  a  corresponding  increase  in  the  number 
of  the  pelvic  organs,  including  the  limbs.  Thus  it  follows 
that  supernumerary  hind  limbs  may  arise  from  dichotomy 


SAGBAL    TERATOMAS 


425 


affecting  the  embryonic  limb,  or  from  cleavage  of  the  caudal 
end  of  the  trunk.  The  two  modes  also  hold  good  for  redupli- 
cation of  the  fore  limbs.  The  limbs  may  project  from  the 
ventral  aspect  of  the  pelvis,  or  be,  as  it  were,  dislocated  on  to 
the  dorsal  surface.  Occasionally  they  occupy  a  position  mid- 
way between  these  two  extremes  and  lie  more  or  less  parallel 
with  the  normal  hind  limbs. 

In  some  individuals  one  pair  of  supernumerary  limbs  fuse 
throughout  their  length  (Fig.  210),  and  in  others  one  limb  is 


--^  DIMPLE 


Fig.  211. — Sacral  teratoma  with  a  suj)emumerary  leg. 

suppressed  (Fig.  211),  but  it  is  a  noteworthy  fact  in  its 
bearing  on  the  cleavage  theory  that  in  all  specimens  of  super- 
numerary limbs  due  to  posterior  cleavage  there  is  an  accessary 
but  usually  imperforate  anus.  In  the  case  of  Jean  Battista 
dos  Santos  of  Portugal,  described  in  1846  by  W.  Acton, 
and  nineteen  years  later  by  Ernest  Hart  in  London,  and  by 
Handyside  in  Edinburgh,  there  was  not  only  an  additional 
(imperforate)  anus,  but  the  man  had  two  functional  penes.  It 
is  also  an  interesting  fact  that  malformed  individuals  of  this 
kind,  whether  male  or  female,  are  capable  of  producing 
healthy,  well-formed  offspring,  the  most  striking  example 
being  the  Siamese  twins,  Chang  and  Eng  Bunker.  They 
married  sisters  :  Chang  had  ten  children,  Encf  twelve.  One 
boy  and  one  girl  of  Chang's   were  deaf  and    dumb;    there 


426 


TERATOMAS 


was  no  other  blemish  in  the  famih'es  of  the  twins.  The 
pygopagus  twins,  Rosa-Josepha  Blazek,  when  32  years  of 
age  conceived  and  brought  forth  a  hving  son  at  Prague. 
The  child  was  in  Rosa's  womb,  but  milk  appeared  in  the 
breasts  of  both  (Trunecek). 

Duplication  of  the  pelvic  limbs  and  of  the  anus  occurs 
frequently  in  sheep,  calves,  and  birds. 

When  the  parasitic  foetus  is  so  suppressed  as  to  form  only 


Fig.  212. — Anterior  dichotomy. 

om  a  photograph  supplied  hy  Dr.    William  Bitcld,  of  Bristol,  July  2(jth,   1856, 
to  Sir  James  Paget.) 

a  shapeless  or  deformed  lump,  such  as  would  be  the  case  in 
Fig.  211  if  the  limb  were  absent,  then  the  mass  would  be 
called  a  teratoma. 

It  is  a  fact  that  the  autosite  has  no  power  of  initiating  in- 
dependent movements  in  the  limbs  of  the  parasite,  neverthe- 
less he  can  localize .  the  prick  of  a  pin  on  the  parasite,  and 
feel  uncomfortable  when  it  is  cold.  In  the  parasitic  fcetus 
represented   in   Fig.   214,   micturition  occurs   independently 


CRANIAL    TERATOMAS  427 

and  without  the  knowledge  of  the  autosite  until  he  feels 
urine  trickling  over  him.  Involuntary  twitchings  can  some- 
times be  induced  in  teratomas  by  irritating  them. 

Anterior  dichotomy.  —  Cleavage  may  affect  the  facial 
portion  only  and  produce  reduplication  of  the  jaws,  or  it  may 
involve  the  head  and  produce  a  two-headed  individual. 
Should  it  extend  to  the  thoracic  region  of  the  spine,  then  an 
animal  with  two  heads  and  reduplicated  fore-limbs  is  the 
result.  When  partial  dichotomy  attacks  the  head  the  median 
parts  of  the  reduplicated  face  are  so  conjoined  and  malformed 
that  they  are  sometimes  found  hanging  in  the  pharynx,  being 
attached  to  its  roof  by  a  pedicle.  Such  tumours  are  called 
hasicranial  teratomas :  the  majority  of  tumours  called 
pharyngeal  dermoids  are  of  this  nature. 

In  order  to  appreciate  the  difficulty  of  interpreting  the 
nature  of  tumours  covered  with  skin  and  bearing  teeth, 
reference  should  be  made  to  the  section  on  Heterotopic 
Teeth  (Chap.  liv.).  It  is  curious  to  find  in  a  teratoma  an 
organ  like  a  vertebra,  or  a  tooth,  or  a  tongue  well  developed, 
although  the  rest  of  the  fcetus  is  represented  by  a  mere 
conglomeration  of  tissue. 

Among  remarkable  instances  of  anterior  dichotomy,  Millie- 
Christine,  the  blended  Tocci  brothers,  and  Rosa-Josepha  have 
been  carefully  described.  This  form  of  dichotomy  has  been 
studied  in  fishes,  tortoises,  calves,  birds,  and  snakes. 

The  details  of  the  remarkable  child  represented  in  Fig.  212 
were  supplied  to  Sir  James  Paget  by  Dr.  William  Budd,  of 
Bristol,  in  1856.  With  the  exception  of  the  extraordinary 
excrescence,  he  writes,  "  the  child  presents  no  deviation  from 
the  normal  type,  but  is  as  comely  a  little  thing  as  you  would 
wish  to  see.  Every  movement  and  every  act  of  the  natural 
face  is  simultaneously  repeated  in  the  second  face  in  the  most 
perfectly  consensual  manner.  When  the  natural  face  sucks 
the  second  mouth  sucks."  Crying  and  yawning  occurred  at 
the  same  time  in  the  two  faces. 

I  have  ventured  to  publish  this  case  because,  so  far  as  my 
knowledge  of  teratology  extends,  no  similar  case  in  the 
human  subject  is  known.  The  fact  "that  every  movement 
and  every  act  of  the  natural  face  is  simultaneously  repeated 
in  the  second  face  in  the  most  perfectly  consensual  manner  " 


428 


TERATOMAS 


is  quite  in  accord  with  what  has  been  observed  in  calves  the 
subject  of  "  partial  anterior  dichotomy." 

Thus  far  we  have  been  concerned  with  duplicated  parts 
that  reach  such  a  standard  of  development  that  their  identifi- 
cation is  a  matter  neither  of  difficulty  nor  of  doubt.  It  will 
now  be  necessary  to  consider  the  meaning  of  those  attached 
parts  named  j)arasitic  foetuses,  and  the  irregular  masses  called 
teratomas. 

It  happens,  and  not  infrequently,  that  in  cases  of  twins 

.  one  oi  them  is  of  natural  shape  and  viable,  but  the  other  is 

very  imperfectly  developed,  and  as  it  lacks  a  heart  (or  if  this 

organ  be  present  it  is  rudimentary  and  functionless)  it  is  said 

to  be  acardiac.     The  degree  of  development  varies  greatly :  in 


Tulaercle  mark- 
ing the  end  of 
the  rudimentary 
sxjinal  cord. 


\i  i.rdiac  fcetus. 


some  the  foetus  may  be  complete  save  head  and  neck.  In 
rarer  cases  the  foetus  may  be  merely  represented  by  an 
irregular-shaped  mass  consisting  of  oedematous  integument 
surrounding  a  portion  of  the  skeleton,  usually  an  innominate 
bone  with  the  bonj^  elements  of  a  lower  limb. 

In  some  specimens  no  particular  skeletal  element  is  recog- 
nizable, but  a  portion  of  intestine  or  rudiments  of  the  genito- 
urinary organs  can  be  detected.  To  such  examples  of  acar- 
diacus  the  adjective  amorphous  is  applied,  and  to  French 
teratologists  they  are  known  as  "  anidian  monsters."  An 
acardiac  such  as  Figc.  213  has  been  described  as  a  dermoid  of 


AGABDIAGS 


429 


the  umbilical  cord  (Budin).  In  very  exceptional  cases  the 
acardiac  may  be  so  thoroughly  amorphous  that  it  is  impos- 
sible to  decide  its  nature  until  it  has  been  submitted  to  a 
microscopic  examination  (Lea). 

Acardiacs  are  not  necessarily  separate  from  the  well- 
developed  twin,  but  may  be  attached  to  it  in  a  variety  of 
ways. 


Fig.  214. — Laloo,  a  Hindoo,  with  an  acardiac  parasite  attached  to  his  thorax. 


In  the  common  form  the  shapeless  mass  is  connected  with 
the  dorsal  aspect  of  the  sacrum,  and  simulates  a  spina  bifida 
sac,  or  the  form  of  congenital  sacro-coccygeal  tumour  which 
arises  in  the  postanal  gut.  These  sacral  teratomas  often 
twitch  when  irritated,  and  this  is  a  valuable  diasrnostic  sicfn. 
In  rarer  cases  teratomas  have  been  observed  in  the  thoracic 
and  abdominal  cavities  connected  with  the  vertebral  column. 


430 


TERATOMAS 


They  are  not  uncommon  on  the  head,  particularly  in  relation 
with  the  jaws  (p.  435). 

The  explanation  of  acardiac  foetuses,  whether  free  or  para- 
sitic, seems  to  be  this :  Two  embryos  arise  from  a  single 
ovum  ;  in  some  instances  the  cleavage  is  complete,  but  the 
heart  of  one  embryo  is  defective.  The  circulation  of  the  two 
embryos  is  continuous  at  the  placenta,  and  the  heart  of  the 
normal  embryo  is  able  to  maintain  in  a  measure  the  blood- 
current  in  its  companion,  and  thus  save  it  from  complete 


Placenta  of  the 
acardiac. 


Artery  and  vein  dis- 
tributing blood  to 
the  acardiac. 


Umbilical  cord  of  the  healtliy 
twin.  ' 


Fig.  215. — Placenta  from  twins,  one  of  which  was  an  acardiac. 

(After  Astley  Cooper.) 

suppression.  Sir  Astley  Cooper  demonstrated  this  compen- 
satory mechanism  in  the  case  of  an  acardiacus  placed  in  his 
hands  by  Dr.  Hodgkin.  An  inspection  of  the  drawing  of  the 
placenta  from  this  case  (Fig.  215)  shows  that  the  umbilical 
vessels  in  the  two  sections  of  the  compound  placenta  were 
directly  continuous. 

In  the  case  of  a  parasitic  acardiac — e.g.  Laloo — the  circula- 
tion must  be  directly  maintained  by  the  heart  of  the  autosite, 
as  an  independent  heart  has  not,  so  far  as  I  am  aware,  been 
detected  in  the  parasite.  The  blood-current  is  always  ex- 
tremely sloAV  in  the  acardiac,  and  thermometric  observations 


FAEASITIG  FCETUS 


431 


demonstrate  that  its  temperature  is  several  degrees  lower  than 
that  of  the  autosite. 

Thus  a  study  of  the  circumstances  surrounding  the  de- 
velopment of  twins  and  duplex  monsters  brings  us  to  the 
conclusion  that  a  teratoma  ma}''  arise  either  from  partial 
dichotomy  of  the  trunk-axis  of  the  embryo  or  from  complete 
dichotomy.  In  the  latter  case,  while  one  twin  has  gone  on  to 
full  development,  the  growth  of  the  other  has  been  arrested, 
and  in  some  cases  the  suppression  has  been  so  great  that  the 


Fig.  216.— Sacred  ox  with  a  parasitic  calf  (India). 

companion  foetus  is  represented  by  a  deformed  or  shapeless 
mass  consisting  of  integument  covering  ill-formed  pieces  of 
the  skeleton  and  portions  of  viscera.  The  best  evidence 
that  parasitic  foetuses  and  teratomas  arise  from  cleavage  is 
this  :  we  always  find  hke  parts  attached  to  hke  parts — head 
to  head,  pelvis  to  pelvis,  thorax  to  thorax.  To  this  I  do  not 
know  an  exception. 

Treatment. — Parasitic  acardiacs  and  conjoined  twins  are 
so  valuable   as   sources   of  gain   in  fairs,   shows,   and  large 


432  TERATOMAS 

cities  that  the  parents,  or  the  unscrupulous  individuals  who 
get  possession  of  these  children,  will  not  permit  operative 
interference. 

The  xiphopagous  twins  Radica  and  Doodica  (Fig.  209) 
are  remarkable  in  this  respect,  for  Doodica  became  the  victim 
of  tuberculous  peritonitis  and  Doyen  divided  the  uniting  band. 
Doodica  died  six  hours  after  the  operation,  but  Radica 
survived  (1902). 

In  the  AVest  the  parasitic  foetus  is  a  source  of  unholy  gain  ; 
among  Hindoos  it  is  an  object  of  veneration,  especially  when 
the  autosite  is  a  cow. 

Acton,  W.,  "  An  account  of  a  Case  of   Partial  Double  Monstrosity." — Med.- 

Chir.  Trans.,  1846j  xxix.  103. 

Budin,  P.,   "  Note   sur   une   Tumeur  da   Cordon   Ombilical." — Pror/res  Med., 

1887,  V.  550. 

Geoffrey   Saint-Hilaire,    Isidore. — "Anomalies   de   I'Organisation,"  1836,  iii. 
166. 

Handyside,  P.  D.,  "  Observations  on  the  Arrested  Twin  Development  of  Jean 

Eattista  dos  Santos,  born  at  Faro  in  Portugal,  in  1846." — Edin.  Med.  and 

Surg.  Journ.,  1866,  ii.  833. 
Harris,  R.  P.,  "  The  Blended  Tocci  Brothers  and  their  Historical  Analogues." — 

Amer.  Journ.  of  Obstet..  1892,  sxv.  460. 
Hart,  Ernest,   '■  A  Remarkable  Case  of  Double  Monstrosity  in  an  Adult." — 

Lancet,  1865,  ii.  124. 
Hodgkin,   T.,   and   Cooper,    Sir  A.,  "  The   History  of  an  unusually  formed 

Placenta  and  imperfect  Foetus,  and  of  similar  examples  of  monstrous 

productions." — Guy's  Hasp.  Repts.,  1836,  i.  218. 
Keith,  A.,  "  The  Anatomy  and  Nature  of  two  Acardiac  Acephalic  Foetuses." — 

Trans.  Obstet.  Soc,  1901,  xlii.  99. 
Lea,  A.  W.  W.,  "Report  of  Committee  on  Dr.  Arnold  W.  W.  Lea's  specimen  of 

Tumour  expelled  from  Uterus  during  labour  at  term,  exhibited  January 

4th,  1899."— I'mHs.  Obstet.  Soc,  1900.  xli.  219. 
Trunecek,   C,   "  L'Accouchemect   du  Pygopage  Rosa-Josepha  Blazek."— Zis 

Se/naine  Med.,  1910,  No.  xx.  299. 

Windle,  B.  C.  A.,  "  On  the  Condition  known  as  'Epignathus."—Jour7i.  Anat.  and 
Phijs.,  1898-99,  xxxiii.  277. 


CHAPTER  XLIII 

TERATOMAS  (Concluded) 
INTERNAL  TERATOMAS 
This  variety  occurs  in  the  thorax,  the  abdomen,  and  the 
cranium ;  in  the  abdomen  it  occasionally  attains  a  degree 
of  development  equal  to  that  found  in  external  parts.  The 
internal  teratoma  differs  from  the  external  kind  in  being 
enclosed  in  a  cyst,  and  it  imperils  the  life  of  the  autosite 
from  mechanical  causes,  and  in  rare  instances  by  displaying 
malignancy  of  a  remarkable  kind.  It  is  unusual  in  these 
cavities  of  the  body  to  find  teratomas  with  limbs  and  organs 
so  shaped  as  to  enable  the  observer  at  once  to  recognize  that 
he  has  before  him  a  very  badly  developed  embryo  enclosed 
within  its  bearer,  and  it  is  customary  to  denominate  such 
conglomerate  lumps  teratoid  tumours. 

Intra-abdominal  teratomas. — A  parasitic  foetus  within 
the  abdominal  cavity  is  extremely  rare;  one  of  the  best-known 
examples  was  described  by  Young  in  1808,  under  the  title  of  "A 
Foetus  found  in  the  Abdomen  of  a  Boy."  In  this  instance  a 
large  cyst  was  found  in  the  belly  of  an  infant  a  year  old. 
The  post-mortem  examination  was  carefully  conducted,  and 
the  cyst,  which  lay  behind  the  peritoneum,  contained,  in 
addition  to  a  large  quantity  of  fluid,  the  pelvis,  lower  limbs, 
and  genital  organs  of  a  foetus  (Fig.   217). 

Five  years  later  Phillips  described,  in  a  letter  to  Sir 
Benjamin  Brodie,  a  case  in  which  parts  of  a  foetus  were 
found  in  a  tumour  lodged  in  the  abdomen  of  a  girl  2|  years 
of  age.  The  brief  description  contains  this  statement :  "  The 
cyst  in  the  abdomen  contained  fluid  and  solid  matter ;  the 
latter  contained  a  large  bone  resembling  a  tibia  covered  with 
muscle,  and  small  bones  like  a  tarsus.  There  were  cystic 
spaces  containing  sanious  fluid.  The  liver  bore  marks  of 
inflammation  and  w\as  studded  with  tubercles." 
2  c  433 


434 


TERATOMAS 


Lexer  lias  described  a  teratoma  as  big  as  a  fist  removed 
during  life  from  a  girl  7  weeks  old ;  it  was  situated  in  the 
foramen  epiploicum  and  lay  under  the  liver.  This  tumour 
had  cystic  and  solid  parts ;  the  latter  represented  skeletal 
and  visceral  elements.  The  baby  did  not  survive  the 
operation. 

Intrathoracic  teratomas. — Tumours  described  as  derm- 
oids within  the  thorax  have  been  recorded  by  many  writers. 
They  are  rare,  but  cause  much  distress  to  the  patients  who 
possess  them.     The  majority  occupy  the  mediastinum  and 


Fig.  217- — ^A  foetus  which  was  found  enveloped  in  a  cyst  in  the  abdomen  of  a  hoy. 

(After  Youinj,  1808.) 

grow  downwards  to  one  or  other  side,  compressing  the  lung. 
A  dermoid  has  been  observed  anteriorly  to  the  pericardium 
(Hale  White). 

Many  of  the  cases  have  been  recorded  as  "  dermoids  of 
the  lungs,"  but  all  the  later  reporters  agree  that  the  involve- 
ment of  the  lung  is  secondary.  When  the  bronchi  become 
implicated  by  such  a  tumour,  "hair-spitting"  occurs,  due  to 
the  cyst  opening  into  the  air-passage  as  a  consequence  of 


INTBAGBANIAL   TERATOMAS  435 

suppuration.  The  inner  wall  of  such  cysts  is  often  beset 
with  nipple-like  processes  of  skin. 

Ritchie  has  described  a  teratoma  which  occupied  the 
mediastinum  of  a  man  of  24  years  :  attached  to  and  forming 
part  of  its  wall  was  a  solid  tumour  containing  tissue  micro- 
scopically identical  with  that  of  a  chorion-epithelioma.  The 
lungs  and  liver  contained  secondary  deposits.  It  is  somewhat 
remarkable  to  lind  among  such  highly  organized  tumours, 
whose  extreme  specialization  would  almost  pass  as  a  brand 
of  innocency,  illustrations  of  what  has  already  been  mentioned 
in  connexion  with  other  Groups,  that  each  genus  of  the 
so-called  benign  tumours  contains  varieties  which  .shade  away 
indefinitel}^  from  the  type  species  and  display  malignancy. 

Intracranial  teratomas. — In  the  chapters  dealing  with 
sequestration  dermoids  it  is  pointed  out  that  these  tumours 
are  found  in  connexion  with  the  scalp  and  in  association 
with  the  tentorium,  and  their  presence  in  these  situations 
may  be  attributed  to  small  portions  of  surface  epiblast 
sequestered  in  the  course  of  the  development  of  the  skull 
(p.  461).  Such  dermoids  exhibit  the  same  characters  as  those 
so  commonly  found  near  the  angles  of  the  orbits  (p.  455). 

Complex  tumours  of  the  teratoid  type  are  occasionally 
found  at  the  base  of  the  skull,  and  usually  occupying  the 
pituitary  fossa.  Teratomas  in  this  situation  resemble  those 
found  at  times  in  the  pharynx,  and  contain  striped-muscle 
fibre,  hyalin  cartilage,  glandular  tissue,  and  cysts  lined  with 
squamous  epithelium.  In  one  carefully  described  specimen 
ganglion-cells  and  white  nerve-fibres  were  present :  some  of  the 
nerve-bundles  had  a  cross  section  as  big  as  the  radial  nerve. 
Pituitary  teratomas  have  been  described  by  Lawson,  Bowlby, 
Hale  White,  Sainsbury,  Buzzard,  and  Bostroem.  Rows  de- 
scribed two  examples  which  occurred  in  men ;  one  was  aged 
77  and  the  other  73.  Intracranial  dermoids  or  embryomas 
occur  in  the  basal  parts  of  the  brain,  in  or  near  the  middle  line. 
They  grow  very  slowly,  and  rarely  produce  symptoms. 

Teratomas  of  the  pharynx  and  palate. — It  is  noteworthy 
that  the  parts  in  relation  with  the  cephalic  as  well  as  the 
caudal  extremity  of  the  notochord  are  common  situations  for 
teratomas  containinsr  formed  orsfans  and  tissues  such  as  bone, 
skin,  striped  muscle,  nerves,  epithelium,  and  occasionally  a 


436 


TERATOMAS 


tooth,  but  devoid  of  any  shape  and  arrangement  of  the  parts 
to  suggest  a  foetus,  though  arising  in  the  same  manner  as  a 
parasitic  foetus.  In  the  palate  and  naso-pharynx,  teratomas 
usually  take  the  form  of  pedunculated  tumours  clad  with 
skin  which  is  often  pilose  (Fig.  218).  The  core  of  these 
tumours  consists  of  connective  tissue  which  may  contain 
hyalin  cartilage  and  a  variable  amount  of  striped  muscle- 
tissue.  In  many  cases  it  is  difficult  to  decide  whether  the 
tumour  grows  from  the  palate,  or  from  the  base  of  the  skull 
and  projects  through  a  gap  in  the  bony  palate.  Sometimes 
the   attachment   is  so   slender   that   the  tumour   undergoes 


Fi^.  218. — Pedunculated  skin-clad  pilose  tumour  from  the  pharyngeal  aspect  of  the 
soft  palate.     {A riiold. ) 

spontaneous  detachment ;  in  the  case  reported  by  Lambl  the 
child,  swallowed  the  tumour  and  voided  it  next  day  by  the 
anus.  Occasionally  the  tumour  is  sessile,  and  may  even 
project  into  the  floor  of  the  pituitary  fossa  and  compress  the 
optic  nerves  and  tracts. 

Windle  has  collected  the  literature  relating  to  teratomas 
of  the  pharynx  under  the  title  of  Epignathus,  and  has  sum- 
marized the  various  views  in  regard  to  the  nature  of  this 
condition. 

In  describing  teratomas  care  was  particularly  taken  to 
emphasize  the  fact  that  many  cases  of  duplicity  of  parts 
depended  on  dichotomy.  Cleavage  may  be  so  slight  at  the 
cephalic  end  of  the  embryo  as  only  to  involve  the  face,  or 
even  the  jaws.      Of  this  I  have  described  several  specimens, 


RECTAL    TERATOMAS  437 

which  make  it  clear  that  precisely  the  same  thing  takes 
place  in  connexion  with  the  jaws  as  with  the  pelvic  limbs. 
When  this  is  the  case,  the  supernumerary  maxillae  fuse 
together  and  are  impacted  in  the  naso-pharynx  and  fixed  to 
the  base  of  the  sphenoid,  or  hang  as  a  pedunculated  tumour 
in  the  naso-pharynx.  I  have  examined  a  large  number 
of  specimens  (many  of  which  are  preserved  in  the  splendid 
Teratological  Collection  of  the  museum  of  the  Royal  College 
of  Surgeons),  in  which  every  gradation  is  traced,  from  well- 
formed  maxillae  with  unerupted  teeth  to  a  confused  lump 
consisting  of  teeth,  bone,  and  cartilage  impacted  in  the 
palate  but  firmly  united  by  a  broad  base  to  the  sphenoid  in 
the  neighbourhood  of  the  pituitary  fossa. 

Teratomas  connected  with  the  rectum  and  colon.— In 
order  to  appreciate  the  nature  of  such  tumours  arising  in  the 
immediate  neighbourhood  of  the  rectum,  it  will  be  necessary 
to  consider  a  few  points  connected  with  the  embryology  of 
this  portion  of  the  alimentary,  canal.  In  the  early  embryo, 
the  central  canal  of  the  spinal  cord  and  the  alimentary  canal 
are  continuous  around  the  caudal  extremity  of  the  notochord. 
This  passage,  which  brings  the  developing  cord  and  gut  into 
such  intimate  union,  is  known  as  the  neurenteric  canal. 
When  the  proctodseum  invaginates  to  form  part  of  the 
cloacal  chamber  it  meets  the  gut  at  a  point  some  distance 
anterior  to  the  sjDot  where  the  neurenteric  canal  opens  into 
it ;  hence  there  is  for  a  time  a  segment  of  intestine  extending 
behind  the  anus,  and  termed  in  consequence  the  "postanal 
gut."  Afterwards  this  postanal  section  of  the  embryonic  in- 
testine disappears.  There  is  good  reason  to  regard  the 
postanal  gut  as  the  source  of  that  variety  of  congenital 
sacro-coccygeal  tumour  which  was  named  by  Braune  and 
several  writers  who  followed  him  "  congenital  cystic  sarcoma." 
These  will  be  referred  to  as  tumours  of  the  postanal  gut.  In 
addition,  it  will  be  necessary  to  consider  dermoids  situated 
between  the  rectum  and  the  hollow  of  the  sacrum — postrecta.l 
teratomas — and  certain  pedunculated  tumours  situated  Avithin 
the  rectum — rectal  teratomas. 

Tumours  which  arise  in  the  postanal  gut  exhibit  a  definite 
structure;  they  are  composed  of  closed  vesicles  lined  with 
glandular  epithelium,  and  contain  glue-like  fluid.     Many  of 


438  TERATOMAS 

these  tumours  are  composed  of  cysts  and  duct-like  passages 
lined  with  cubical  epithelium,  held  together  by  richly  cellular 
connective  tissue.  In  many  situations  the  epithelium  is 
columnar,  set  upon  flatter  cells.  The  cysts  are  filled  with 
ropy  mucus,  and  vary  in  size  from  a  nut  to  the  smallest 
space  visible  to  the  naked  eye ;  many  contain  intracystic 
processes.  These  tumours  present  such  definite  characters 
that  they  are  sure  to  attract  attention,  and  their  large  size 
makes  them  very  conspicuous. 

Middeldorpf  was  the  first  to  associate  clearly  a  congenital 
sacro-coccygeal  tumour  with  the  postanal  gut.  His  specimen 
was  removed  from  the  neighbourhood  of  the  anus  of  a  girl  a 
year  old.     The  tumour  contained  connective  tissue,  mucous 


Fig.  219. — Rectal  teratoma  which  contained  brain-suhstance  enclosed  in  a  hony 
capsule  :  from  a  woman  aged  25.     {After  DanzeJ.) 

membrane  with  characteristic  follicles,  submucous  tissue,  and 
longitudinal  and  circular  laj^ers  of  muscle-fibres.  I  had  come 
to  the  same  conclusion  in  regard  to  the  probable  origin  ot 
these  tumours  before  the  publication  of  Middeldorpf 's  paper ; 
his  case  is  the  most  conclusive  on  record. 

Postrectal  teratomas  are  very  rare,  and  do  not  form  such 
large  projecting  masses  as  the  preceding  species.  In  many 
instances  they  are  not  noticed  until  after  infant  life,  and  their 
clinical  tendencies  are  of  a  different  character.  An  excellent 
example   of  a   postrectal  teratoma  exists  in   the  Middlesex 


POSTBEGTAL   TERATOMAS 


439 


Hospital  Museum  :  it  contains  grease,  hair,  and  a  tootli.  It 
was  found  in  the  course  of  a  post-mortem  examination.  The 
tumour  remains  in  situ  on  the  rectum. 

Such  tumours  also  occur  as  surgical  surprises,  especially 
when  they  attain  very  large  dimensions  and  extend  upwards 
behind  the  pelvic  peritoneum  of  men  and  women.  Ord 
recorded  a  remarkable  case  which  occurred  in  a  man  28  years 
old ;  the  mass  weighed  fourteen  pounds.  Page  successfully 
removed  a  teratoma,  weighing  three  pounds,  which  occupied 
the  hollow   of  the   sacrum   in  a  woman  of  47  years ;  it  lay 


Fig.  220. — Cfficum  and  adjacent  portion  of  the  ileum  of  a  man  :  a  dermoid  occupies 
tlie  angle  between  the  ileum  and  the  cfficum.  (The  specimen  is  in  the  possession 
of  Mr.  A.  Hall,  ShefEeld.) 

behind  the  rectum.  The  pultaceous  matter  was  evacuated 
through  an  incision  in  the  perineum ;  the  cyst-wall  was  then 
successfully  enucleated. 

Skutsch  has  recorded  two  examples  of  postrectal  tera- 
tomas, and  collected  the  chief  German  cases.  One  of  the 
records  states  that  the  patient  was  pregnant,  and  he  was  able 
to  empty  and  partially  enucleate  the  tumour  through  an 
incision  in  the  perineum  without  disturbing  the  pregnancy. 

Postrectal  teratomas  sometimes  open  spontaneously  in  the 
perineum ;  the  fistula  is  usually  situated  in  the  middle  line  of 
the  perineum  near  the  tip  of  the  coccyx.     Keen  removed  a 


440  TERATOMAS 

postrectal  tumour  from  a  girl  3?,  years  of  age;  in  the  middle 
there  was  a  fistula  which  led  upwards  to  the  third  piece  of 
the  sacrum ;  it  contained  fat,  cartilage,  etc.  The  tubular 
tract  resembled  a  trachea,  and  possessed  imperfect  rings  of 
cartilage,  and  was  lined  with  ciliated  epithelium. 

Teratomas  of  the  rectum.— Several  examples  have  been 
described  grooving  from  the  mucous  membrane  of  the  rectum 
(Fig.  219) ;  a  curious  feature  in  these  cases  is  that  the 
tumours  are  furnished  with  long  locks  of  hair,  which  pro- 
trude from  the  anus  and  annoy  the  patients  (Danzel,  Port). 
Like  postrectal  teratomas,  they  sometimes  contain  teeth. 

Nearly  all  the  recorded  examples  of  rectal  teratomas  have 
occurred  in  women,  and  this  formerly  gave  some  support  to  the 
suggestion  that  they  arose  in  the  ovary,  and  eroded  their  way 
into  the  rectum.  In  one  recorded  case  a  teratoma  was  found 
between  the  layers  of  the  mesosigmoid;  the  patient  died 
in  consequence  of  an  operation  performed  for  its  removal  ; 
at  the  autopsy  a  dermoid  was  found  in  the  connective 
tissue  of  the  pelvis.  The  ovaries  were  normal  (Moynihan). 
A  pedunculated  teratoma  hanging  from  the  mucous  mem- 
brane of  the  sigmoid  flexure  led  to  intussusception  in  a 
girl  aged  16  (Glutton). 

The  study  of  dermoids  and  teratomas  connected  with  the 
rectum  is  important  and  puzzling :  some  of  them  exhibit  the 
characters  of  teratomas,  and  others  should  find  a  place  with 
the  simpler  varieties  of  dermoids.  The  idea  that  some  of 
them  are  included  foetuses  is  reasonable  when  they  are  situated 
around  the  terminal  section  of  the  gut,  but  this  can  scarcely 
be  entertained  when  the  tumour,  as  in  the  case  described  by 
Moynihan,  is  in  relation  with  the  sigmoid  flexure  of  the  colon. 
A  remarkable  dermoid  is  represented  in  Fig.  220,  lodged  in 
the  angle  formed  by  the  junction  of  the  ileum  and  the  csecum : 
the  tumour  lies  between  the  layers  of  the  peritoneal  fold 
extending  from  the  termination  of  the  ileum  to  the  mesentery 
of  the  vermiform  appendix.  It  contained  the  usual  pulta- 
ceous  matter  and  hairs.  The  cavity  was  lined  with  stratified 
epithelium,  but  lacked  a  stratum  granulosum.  The  sj^ecimen 
was  obtained  in  the  course  of  a  post-mortem  examination  on 
the  body  of  a  man  by  Mr.  Arthur  HaU,  who  kindly  gave  me 
every  facility  for  examining  the  specimen. 


REFERENCES  441 

Bostroem,    "  Ueber    die   pialen    Epidermoide,    Dermoide,  und   Lipome,   und 

duralen  Dermoide." — Centrabl.f.  path.  Atiat.,  1807,  1. 
Braune,  W.,  "  Die  Doppelbildungen  und  angeboren  Geschwulste  der  Kreuz- 

beingegend,"  1862,  40  ct  seq. 
Buzzard,  F.,  Trans.  Path.  Soc,  1904,  Iv.  330. 
Glutton,    H.  H.,  "Pedunculated  Dermoid  Tumour  from  the  Sigmoid  Flexure." 

—Trans.  Path.  Soc,  1886,  xxxvii.  252. 
Middeldorpf,     K.,    "Zur    Kenntniss     der    angeboren    Sacralgeschwulste."^ 

Vircliow's  Arch.  f.  path.  Anat.,  1885,  ci.  37. 
Moynihan,  B.  G.  A.— Lancet,  1898,  i.  80. 
Ord,  W.  M.,  and  Sewell,  C.  B.,  "  An  account  of  a  Large  Dermoid  Cyst  found  in 

the  Abdomen  of  a  Man." — Med.-Chir.  Trans.,  1880,  Ixiii.  1. 
Page,  Frederick,  "  Large  Extraperitoneal  Dermoid  Cyst  successfully  removed 

through  an  Incision  across  the  Perineum,  midway  between  the  Anus  and 

Coccyx."— Brit.  Med.  Journ.,  1891,  i.  406. 
Port,   Heinrich,    "  Dermoid  Tumour  from  the  Rectum." — Trans.  Path,  Soe. 

1880,  xxxi.  307. 
Rows,  E.  G,,  "  Two  Cases  of  Embryoma  in  the  Frontal  Lobes  of  the  Brain." 

—Rev.  of  Nexirol.  a/nd  Psyehiatry,  1906,  iv.  338. 
Skutsch,    F.,     "  Ueber    die    dermoid    Cysten    des     Beckenbindegewebes." — 

/£itschr.  f.  Gel.  und  Gyn.,  1899,  xl.  353. 


CHAPTER  XLIV 
SEQUESTRATION    DERMOIDS 

Dermoids  are  tumours  furnished  with  skin  occurring  in 
situations  where  this  structure  is  not  found  under  normal 
conditions.  They  only  possess  the  structures  normal  to  skin, 
such  as  hair,  sebaceous  and  sweat-  glands ;  teeth  are  rarely 
present. 

Dermoids  may  be  arranged  in  two  genera — 

1.  Sequestration  dermoids. 

2.  Tubulo-dermoids. 

Sequestration  dermoids  arise  in  detached  or  sequestered 
portions  of  skin,  chiefly  in  situations  where,  during  em- 
bryonic life,  coalescence  takes  place  between  cutaneous 
surfaces.  A  sequestration  dermoid  occasionally  takes  the 
form  of  a  skin-lined  recess,  but  more  commonly  it  assumes 
the  form  of  a  globular  tumour  with  a  central  cavity  lined 
with  skin,  furnished  with  dermal  elements. 

Dermoids  of  the  trunk. — These  occur  strictly  in  the 
regions  where  the  lateral  halves  of  the  body  coalesce.  This 
line  of  union,  commencing  immediately  below  the  occipital 
protuberance,  extends  along  the  middle  of  the  back  to  the 
coccyx ;  it  then  passes  through  the  perineum  (scrotum  and 
penis  in  the  male")  and  upwards  through  the  umbilicus,  thorax, 
neck  and  chin,  to  terminate  at  the  margin  of  the  lower  lip. 

Dermoids  are  rare  along  the  dorsal  part  of  this  line  and 
are  apt  to  be  mistaken  for  spina  bifida  sacs,  especially  when 
situated  in  the  lumbo-sacral  region.  A  man  aged  22  had 
a  congenital  tumour  in  this  region  which  had  been  regarded 
as  a  spina  bifida  sac  (Fig.  221).  It  had  never  caused  him 
inconvenience  until  a  few  days  before  his  admission  into 
the  hospital,  when  it  inflamed,  burst,  and  discharged  a 
quantity   of    foul-smelling   sebaceous    material    mixed    with 

442 


DEBMOinS  OF  TEE   TRUNK 


443 


hairs.  The  cavity  was  freely  opened  and  cleared  of  de- 
composing material.  The  skin  lining  the  interior  of  the 
dermoid  was  beset  with  pores  of  large  size,  corresponding  to 
the  orifices  of  sAveat-glands ;  when  the  patient  perspired, 
drops  of  sweat  could  be  seen  oozing  from  these  pores.  This 
skin  also  contained  nerves,  for  the  man  could  localize  the 
prick  of  a  pin  on  the  interior  of  the  dermoid  as  easily  as  one 
made  upon  the  skin  surrounding  the  tumour.      When  the 


Fig.  221. — Dermoid  in  the  lumbo- sacral  region  of  a  man  22  years  of  age. 

tumour  was  removed,  the  spinous  processes  underlying  it 
were  found  to  be  unusually  short  and  surrounded  by  fat. 

Rarely  dermoids  are  associated  with  spina  bifida.  Gilbert 
Barling  observed  such  a  combination  in  a  child  2  years  old 
affected  with  spina  bifida  occulta ;  the  skin  covering  the  de- 
fective spines  presented  the  hair-field  usual  in  these  cases. 
In  the  tissues  immediately  over  the  stunted  spinous  pro- 
cesses a  dermoid  was  found  containing  sebaceous  material 
and  hair  (Fig.  222). 

It  is  very  rare  to  find  dermoids  within  the  spinal  canal. 


444 


DERMOIDS 


An  interesting  instance  of  this  has  been  recorded  by  Hale 
White.  It  grew  in  the  thoracic  region  of  the  spine,  and 
produced  paraplegia.  Laminectomy  was  performed  on  the 
patient,  a  man  26  years  of  age,  but  the  operation  was  not 
successful. 

Faulty  coalescence  of  the  cutaneous  covering  of  the  back 
often  occurs  over  the  lower  sacral  vertebrae,  and  gives  rise  to 
small  congenital  sinuses  known  as  "postanal  dimples"  and 
"  coccygeal  sinuses."  These  recesses  are  lined  with  skin  fur- 
nished with  hairs,  sebaceous  and  sweat-  eflands.  Sometimes 
they  measure  10  mm.  in  depth.  As  a  rule  they  are  single, 
and  often  accompany  lumbo-sacral  spinal  bifida.  Though 
most   commonly    seen   over  the   coccygeal   or  the   last  two 


Fig.  222. — Section  of  three  thoracic  vertebras  with  a  small  dermoid  situated 
over  two  stunted  spinous  processes. 

sacral  vertebrae,  I  have  seen  them  as  high  as  the  fourth 
lumbar  vertebra,  and  always  exactly  in  the  middle  line. 

These,  dimples  are  interesting,  for — as  will  be  shown  after- 
wards— in  many  situations  where  sequestration  dermoids 
occur,  similar  cutaneous  recesses  are  also  seen.  An  examina- 
tion of  such  a  sinus  serves  to  show  that  if  its  external  orifice 
became  occluded,  without  the  deeper  parts  becoming  obliter- 
ated, we  should  have  the  germ  of  a  dermoid,  for  the 
numerous  glands  in  the  walls  would  be  active,  and  their 
secretion,  with  the  shed  epithelial  scales  and  hairs,  would 
soon  cause  it  to  enlarge  and  assume  such  proportions  as  to 
render  it  recognizable  as  a  tumour. 

The  coccygeal  sinuses  are  sometimes  troublesome,  as  hair 
and  dirt  accumulate  in  them  and  lead  to  suppuration.     Clini- 


SCROTAL  DERMOIDS 


445 


cally  a  suppurating  coccygeal  sinus  simulates  an  anal  fistula, 
but  a  little  care  will  prevent  the  surgeon  from  confusing 
between  the  two. 

A  good  physiological  type  of  such  a  sinus  is  furnished  by 
the  interdigital  pouch  of  the  sheep.  This  pouch  (Fig.  223) 
lies  between  the  digits,  and  all  the  dissection  required  to 
expose  it  is  to  separate  the  digits  with  a  sharp  knife,  keeping 
close  to  the  phalanges  of  one  or  the  other  side.  In  adult 
sheep  it  is  always  full  of  shed  wool  and  grit.  Sometimes 
its  orifice   is   occluded    and    it    becomes  a   retention   cyst ; 


Fig.  223. — Median  aspect  of  a  sheep's  digit,  showing  the 
interdigital  pouch. 

suppuration  foUoAvs,  much  to"  the  sheep's  discomfort. 
The  Avails  of  this  pouch  are  full  of  very  large  glands.  In 
order  to  get  satisfactory  sections,  it  is  necessary  to  obtain  the 
digits  from  a  still-born  lamb,  for  as  soon  as  lambs  run  about 
grit  gets  into  the  pouch  and  spoils  the  edge  of  the  knife. 

Dermoids  of  the  scrotum  and  labium. — There  are 
many  good  reasons  for  believing  that  the  majority  of 
dermoids  reported  as  arising  in  the  testicle  were  really  scrotal 
in  origin.  This  was  clearly  the  case  in  a  specimen  described 
by  Bilton  Pollard  as  a  dermoid  of  the  testicle.  The  dermoid 
was  situated  on  the  left  side  of  the  scrotum,  betAveen  the 


446 


DERMOIDS 


testicles,  and  adhered  to  the  back  of  the  left  one  outside  the 
tunica  vaginalis.  It  contained  puttj^-like  material  in  Avhich 
there  were  a  few  grey  hairs.  The  cyst  was  lined  with  stratified 
epithelium  ;  papillse  and  sebaceous  glands  were  detected. 

Dermoids  have  been  described  in  relation  with  the  inguinal 
canal.     The  only  record  which  can  be  relied  on  is  that  by  H.  J. 


Fig.  224. — Dermoid  situated  over  the  junction  of  the  manubrium  and  gladiolus  of 
the  sternum  ;  there  was  also  a  dermoid  near  the  left  cornu  of  the  hyoid  bone. 
The  youth  was  19  years  of  age.     {After  Bramann.) 

Paterson  :  he  removed  a  cyst  of  this  kind  from  the  inguinal 
canal  of  a  man  35  years  of  age.  The  microscopic  examination 
in  this  case  was  very  thorough. 

Dermoids  of  the  labium  are  very  rare  :  on  one  occasion  I 
saw  one  removed  as  big  as  an  orange  from  the  right  labium  of 
a  woman  40  years  of  age.  It  contained  the  usual  pultaceous 
material  and  shed  hair.  The  dermoid  had  burrowed  beneath 
the  deep  fascia  of  the  thigh  and  come  into  relation  Avith  the 
tendon  of  the  adductor  lonsfus  muscle. 


THOU  AG  10  DERMOIDS 


447 


Dermoids  of  the  thorax. — Judging  froin  tlie  few  available 
records,  dermoids  of  the  thorax  are  very  uncommon.  They 
occur  in  two  situations — viz.  on  the  anterior  aspect  of  the 
sternum  and  in  the  thoracic  cavity.  Dermoids  on  the  front 
of  the  sternum  are  situated  in  the  middle  line  near  the 
junction  of  the  manubrium  with  the  gladiolus  (Fig.  224) ;  it 
is  not  uncommon  to  find  a  small  cutaneous  recess  in  this 
situation   exactly   in   the   middle   line   and    resembling   the 


.^' 


Fig.  225. — Dermoid  in  the  epistemal  notch  ;  it  contained  hair  and  pultaceous 
matter,  and  was  superficial  to  the  deep  cervical  fascia. 

coccygeal  sinus.  Sternal  dermoids  have  been  described  by 
Bramann,  Cahen,  and  Glutton. 

An  unusual  situation  for  a  dermoid  is  the  episternal  notch 
(Fig.  225),  and  it  is  easy  to  understand  that  one  in  this 
situation  could  burrow  into  the  superior  mediastinum. 

At  first  o-lance  it  would  seem  difficult  to  account  for  the 
presence  of  a  large  dermoid  within  the  thorax,  but  a  review  of 
the  mode  of  development  of  the  sternum  throws  much  clear 
light  on  the  subject.  The  two  lateral  halves  of  the  sternum 
are,  in  the  early  embryo,  widely  separated  from  each  other ; 
gradually  they  coalesce  in  the  middle  line.     Every  anatomist 


448 


DERMOIDS 


is  aware  that  this  median  coalescence  is  extremely  liable  to  be 
faulty,  and  conditions  occur  like  those  which,  happening  in 
connexion  with  the  medullary  folds,  produce  spina  bifida. 
In  this  line  of  coalescence,  so  far  as  sternal  dermoids  are 
concerned,  we  may  get  skin-lined  recesses  resembling  the 
coccygeal  dimples.  These  sternal  recesses,  or  dimples,  occur 
near  the  junction  of  the  manubrium  with  the  gladiolus, 
and  may  be  more  than  a  centimetre  deep.  Should  a  piece  of 
skin  become  sequestrated  during  coalescence  of  the  thoracic 
walls,  it  may,  during  the  development  of  the  sternum,  be 
dislocated  forwards  to  the  outer  surface,  or  backwards  towards 


Fronto-nasal  plate. 
Globular  process. 


Maxillary  process. 


Mandibular  process. 


Interuasal  fissure. 
Orbito-nasal  fissure. 


Mandibular  iissure. 
lutermandibular  fissure. 


Fig.  226. — Head  of  an  early  embryo  to  show  the  fronto-nasal  plate,  globular 
processes,  and  associated  fissures.     {Modified from  His.) 


the  mediastinum,  conditions  in  every  way  parallel  to  the 
variations  in  the  position  of  cranial  dermoids.  So  long  as  a 
dermoid  on  a  deep  surface  of  the  sternum  remains  small  it 
will  cause  no  trouble,  but  it  is  easy  to  understand  that  a  large 
tumour  would,  if  projecting  into  the  thorax,  encroach  on  the 
pleura.  Even  then  it  would  not  produce  much  disturbance  so 
long  as  air  did  not  gain  access  to  it ;  but  if  by  pressure  the 
wall  of  the  cyst  becomes  so  thin  as  to  allow  air  to  enter  its 
cavity,  or  an  actual  communication  forms  between  the  cyst 
and  a  bronchus  or  the  air-sacs  of  the  lung,  then  suppuration 
with  all  its  disastrous  consequences  will  ensue.  (Intrathoracic 
dermoids  and  teratomas  are  considered  at  p.  484). 

Facial  dermoids. — Dermoids  occur  on  the  face  in  certain 


FACIAL  DERMOIDS 


449 


definite  positions,  such  as  the  inner  and  outer  angles  of 
the  orbit ;  on  the  upper  eyehd ;  in  the  naso-facial  sulcus  ; 
on  the  cheek  slightly  posterior  to  the  angle  of  the  mouth ; 
in  the  middle  line  of  the  chin,  and  on  the  nose. 

In  order  to  appreciate  the  origin  of  dermoids  in  these 
situations  it  is  necessary  to  bear  in  mind  the  relation  of  the 
facial  fissures  in  the  embryo,  which  in  the  adult  are  re- 
presented by  the  orbits,  lachrymal  ducts,  mouth,  and  certain 
furrows  in  the  lips  and  cheek. 

In  the  early  embryo  the  face  is  represented  by  an  opening 


Fig.  227. 


-Face  with  black  lines  to  indicate  the  situation  of  the 
embryonic  fissures. 


from  which  six  fissures  radiate  (Fig.  226).  The  upper  pair 
are  the  orbito-nasal ;  the  lower,  the  mandibular;  the  fifth  and 
sixth  are  the  internasal  and  intermandibular  fissures.  The 
median  fold  projecting  into  the  opening  from  above  is  the 
fronto-nasal  process,  which  ultimately  forms  the  nose.  As  it 
develops,  a  rounded  prominence,  known  as  the  globular 
process,  forms  at  each  angle  and  gives  rise  to  a  portion  of  the 
ala  of  the  nostril  and  the  corresponding  premaxilla.  These 
globular  processes  fuse  together  in  the  middle  line  to  -form 
the  central  piece,  or  philtrum,  of  the  upper  lip.  The  elonga- 
tion of  the  fronto-nasal  process  necessarily  lengthens  the 
orbito-nasal  fissures.  Eventually  the  sides  of  the  fronto- 
nasal plate  coalesce  superficially  with  the  maxillary  processes 
2  D 


450 


DERMOIDS 


in  such  a  way  as  to  leave  a  cleft  on  each  side,  which  becomes 
the  orbit ;  the  line  of  union  being  permanently  indicated  in 
the  adult  by  the  naso -facial  sulcus  or  groove,  and  indicated 
still  more  deeply  by  the  lachr3^mal  duct,  which  is  a  persistent 
portion  of  the  original  orbito-nasal  fissure.  The  union  of  the 
fronto-nasal  plate  with  the  maxillary  processes  completes  the 
nose,  cheeks,  and  upper  lip  (Fig.  227). 


Fig.  228. — Eight  side  of  the  head  of  a  fcetus,  showing  a  large  mandibular  tubercle 
and  an  accessary  tragus. 

The  above  account  indicates  in  a  general  way  the  relation 
of  these  fissures  to  each  other ;  but  it  will  be  necessary,  in 
considering  dermoids  arising  in  them,  to  mention  certain 
details  connected  with  each.  But  here  it  may  be  stated  that 
the  defects  associated  with  any  of  them  are  of  four  kinds : 
1,  the  fissure  may  persist  ;  2,  it  may  close  imperfectly  and 
leave  a  recess  or  puckering  of  the  skin ;  3,  portions  of  the 
surface  epithelium  may  be  sequestered  and  give  rise  to 
dermoids  ;  4,  there  may  be  excessive  coalescence. 

These  conditions  may  be  illustrated  by  the  mandibular 


MANDIBULAR   TUBEBGLE8 


451 


fissure.  In  the  embryo  this  fissure  or  cleft  is  relatively  more 
extensive  than  the  opening  of  the  mouth  which  in  the  adult 
ultimately  represents  it.  In  fishes  the  whole  of  the  mandi- 
bular fissure  persists  as  the  gape ;  but  in  mammals  the 
dorsal  portions  of  the  clefts  are  obliterated  by  the  union  of 
their  margins,  leaving  the  central  portion  as  the  mouth. 
Persistence  of  the  whole  length  of  the  fissure  is  a  rare  defect, 
and  is  known  as  macrostoma,  while  excessive  closure  of  the 
fissure   produces    microstoma.      Imperfect    union    of    those 


^    ^^^      ■! 
Fig.  229. — Head  of  a  dog  showing  the  mandibular  tubercle. 

sections  that  normally  coalesce  gives  rise  to  slighter  imper- 
fections, of  which  some  examples  will  now  be  described. 

Occasionally  we  find  on  one  or  both  cheeks  of  children,  at  a 
spot  varying  from  2  to  4  cm.  behind  the  angle  of  the  mouth, 
a  small  nodule  rarely  exceeding  a  rape-seed  in  size.  Some- 
times there  is  a  depression  or  sinus  in  the  cheek,  surmounted 
by  the  nodule.  Occasionally  the  buccal  mucous  membrane 
presents  a  shallow  recess,  sometimes  a  sinus,  and  occasionally 
a  white  cicatrix  at  a  spot  corresponding  to  the  nodule  on  the 
cutaneous  surface  of  the  cheek. 

These  mandibular  tubercles   and  recesses    are    frequently 


452  DERMOIDS 

associated  with  malformations  of  the  corresponding  auricles, 
as  well  as  other  facial  defects,  such  as  coloboma  of  the  eyelid 
and  pilose  cutaneous  patches  on  the  conjunctiva.  The  largest 
specimen  which  has  yet  come  under  my  observation  occurred 
in  a  still-born  foetus  (Fig.  228).  On  the  right  cheek,  2  cm. 
behind  the  angle  of  the  mouth,  was  a  nodule  the  size  of  a 
rape-seed,  and  immediately  behind  this  a  pedunculated  body. 
The  tubercle  on  the  cheek  consisted  of  dense  connective 
tissue  traversed  by  blood-vessels  and  covered  with  skin  beset 
with  lanugo  and  richly  supplied  with  sweat-  and  sebaceous 
glands  of  large  size. 

In  many  mammals,  especially  dogs,  small  cutaneous 
nodules  furnished  with  vibrissse  may  often  be  detected  in  a 
line  with  the  angle  of  the  mouth  (Fig.  229).  These  nodules 
occupy  positions  corresponding  with  those  of  the  mandibular 
tubercles  of  children. 

There  is  very  little  relationship  between  pathology  and 
poetry,  but  that  very  philosophical  pathologist,  Sir  Samuel 
Wilks,  in  reference  to  my  observation  that  the  usual  position 
of  the  mandibular  tubercle  and  recess  corresponds  with  that 
of  the  dimple  in  the  baby's  cheek,  drew  my  attention  to  the 
following  passage  in  his  Harveian  Oration,  1879:  "From  any 
point  of  view  we  take,  and  upon  whatever  subject  we  fix  our 
gaze,  we  come  to  the  conclusion  that  the  greatest  discovery 
ever  made  by  man  about  himself,  and  of  the  earth  of  which 
he  forms  a  part,  is  the  doctrine  of  evolution. 

" '  The  softest  dimple  in  a  baby's  smile 
Springs  from  the  whole  of  past  eternity, 
Tasked  all  the  sum  of  things  to  bring  it  there.'  " 

Wilks  observed  to  me  how  little  the  poet  (Miss  Bevington) 
divined  that  there  is  a  material  basis  for  these  three  pretty  and 
significant  lines.  Jevons  expressed  the  same  truth  in  the 
following  epigram  :  "  The  origin  of  everything  that  exists  is 
wrapped  up  in  the  past  history  of  the  universe." 

The  intermandibular  fissure. — When  the  mandibular  pro- 
cesses fail  to  coalesce,  the  result  will  be  a  median  cleft  in 
the  lower  lip  extending  to  or  even  beyond  the  chin.  Median 
clefts  of  this  kind  are  very  rare.  Occasionally  such  a  defect 
is  associated  with  a  dermoid  or  a  pair  of  small  nodules  in  the 
skin.      In  terriers  such  nodules  are  almost  constantl}''  present 


MANDIBULAR   TUBERCLES 


453 


between  the  symphysis  and  the  body  of  the  hyoid  bone.  In 
children  with  double  hare-lip  two  sinuses  are  sometimes  seen 
in  the  mucous  membrane  of  the  lower  lip.  Their  orifices  are 
indicated  by  small  but  prominent  papillse.  The  sinuses  are 
large  enough  to  admit  a  probe,  and  they  are  in  some  cases 
2  cm.  deep.  Mucus  exudes  from  them,  furnished  by  glands 
which  beset  the  membrane  lining  their  walls.     These  sinuses 


Fig.  230. — Mother  and  her  two  children  with  mandibular  recesses, 
hare-lip.     {From  a  photograph.) 


Each  had  double 


are  probably  due  to  faulty  coalescence  of  the  intermandibular 
fissure.  This  view  is  strengthened  by  an  observation  of 
Feurer,  who  detected  a  similar  sinus  in  the  upper  lip  of  a  lad 
on  the  right  side  of  the  philtrum  ;  it  corresponded  exactly  to 
the  termination  of  the  naso-facial  fissure. 

For  a  remarkable  observation  in  regard  to  mandibular 
recesses  I  am  indebted  to  Mr.  Nicoll.  A  mother  and  her  two 
children  had  each  a  pair  of  recesses  in  the  lower  lip  (Fig.  230). 
Each  had  double  hare-lip,  and  the  cicatrices  of  successful 
operation  are  clearly  visible.  The  mother  was  one  of  a  family 
of  five,  and  each  had  double  hare-lip  and  a  pair  of  recesses  in 
the  lower  lip. 


454  DERMOIDS 

For  a  long  time  I  thought  that  these  recesses  probably  had 
a  morphological  significance,  and  made  a  Avide  search  through 
the  various  families  of  the  mammalia  for  a  type,  but  without 
success.  A  careful  description  of  the  histology  of  these 
sinuses  is  furnished  by  Madelung.  The  earliest  recorded 
example  in  British  literature  is  by  Arbuthnot  Lane, 

Bramann,     F.,    "  Ueber    die    Dermoide    der    ISlase." — ArcJi.    ■^.    Min.     Chir. 

(Langenbeck),  1890,  xl.  101. 
Cahen,  Fritz,  "  Schweissdrilsen-Eetentionscyste  derBrust." — Deutsche  Zeitschr. 

f' Chir.,  1891,  xxxi.  370. 
Glutton,  H.  H.,  "Large  Dermoid  Cyst  over  the  Sternum." — Trans.  Path.  Soc, 

1887,  xxxviii.  393. 
Feurer,  G.,  "Angeborene  Oberlippenfistel." — Arch.f.  Jclin.  Chir.  (Langenbeck), 

1893,  xlvi.  35. 

Lane,  W.  Arbuthnot,  "  A  Case  in  which  two  Sj'mmetrical  Congenital  Mucus- 
secreting  Cavities  existed  in  the  Lower  Lip." — Trans.  Clin.  Soc,  1891, 
xxiv.  230. 

Madelung,  "Zwei  seltene  Missbildungen  des  Gesichts." — Arch.f.  1dm.  Chir. 
(Langenbeck),  1888,  xxxvii.  271. 

Paterson,  H.  J.,  "  Dermoid  Cyst  of  tlie  Inguinal  Canal." — Trans.  Path.  Soc, 

1903,  liv.  149. 
Pollard,    Bilton,    "  Dermoid    Cyst   of    Test\(i\Q."— Trans.    Path.    Soc,    1886, 

xxxvii.  3i2. 

White,  W.  Hale,  "  Dermoid  Cyst  attached  to  the  Front  of  the  Pericardium." — 
Trans.  Path.  Soc,  1890,  xli.  283. 

White,  W.  Hale,  "  A  Case  in  which  the  attempt  was  made  to  remove  a  Dermoid 
Tumour  which,  growing  in  the  Spinal  Canal,  pressed  upon  the  Spinal 
Covd."— Trans.  Clin.  Soc,  1900,  xxxiii.  140. 


CHAPTER   XLY 
SEQUESTRATION    DERMOIDS  (Concluded) 

Dermoids  of  the  orbito -nasal  fissure. — Dermoids  appear 
in  this  fissure  in  three  situations  :  (1)  at  the  outer  angle  of 
the  orbit ;  (2)  at  the  inner  angle  of  the  orbit ;  (3)  in  the  naso- 
facial  sulcus.  Of  the  three  situations,  by  far  the  most 
frequent  is  the  outer  angle  of  the  orbit,  where  they  form 
rounded  tumours  rarely  exceeding  the  dimensions  of  a  cherry  ; 


Fig.  231. — Dermoid  at  the  outer  angle  of  the  orbit. 

they  lie  in  close  relation  with  the  pericranium  covering  the 
frontal  bone,  which  is  often  deeply  hollowed  to  accommodate 
them.  Dermoids  in  this  region  vary  somewhat  in  regard  to 
their  position ;  sometimes  they  are  quite  close  to  the  external 
angular  process  of  the  frontal  bone,  or  they  may  be  2  cm.  or 
more  posterior  to  it  (Fig.  231) ;  exceptionally  they  are  on  a 
level  with,  or  even  lie  beneath,  the  eyebrow. 

455 


456 


DERMOIDS 


Dermoids  at  the  inner  angle  are  far  less  frequent  (Fig.  232). 
In  this  situation  the  tumour  may  extend  beyond  the  bone  and 
lie  in  intimate  relation  with  the  dura  mater.  It  is  very 
necessary  to  remember  this  in  attempting  the  extirpation  of 
the  dermoid.  In  some  cases  the  tumour  may  have  a  peduncle 
continuous  with  the  dura  mater.     Under  such  conditions  the 


Fig.  232. — Dermoid  at  the  inner  angle  of  the  orbit. 

dermoid  may  transmit  the  cerebral  pulsation ;  it  is  then  apt 
to  be  mistaken  for  a  meningocele. 

Dermoids  occur  not  only  at  the  orbital  angles,  but  some- 
times also  in  the  tissue  of  the  upper  eyelid,  unconnected 
with  either  bone  or  periosteum.  These  smaller  dermoids 
probably  arise  in  the  fissure  between  the  fronto-nasal  plate 
and  the  cutaneous  fold  from  which  this  eyelid  is  formed.  The 
fissure  between  the  two  parts  which  form  an  eyelid  sometimes 
persists.  To  this  defect  the  term  coloboma  of  the  eyelid  is 
applied. 


NASAL  DERMOIDS 


457 


Dermoids  arising  in  the  orbital  angles  are  the  simplest  of 
all  dermoids,  and  though  the  skin  lining  them  is  usually  rich 
in  the  ordinary  cutaneous  elements,  such  as  hair,  sebaceous  and 
sweat-  glands,  complex  structures  such  as  teeth  and  bone,  so 
far  as  my  knowledge  extends,  have  not  been  observed  in  them. 
I  have  satisfied  myself  that  the  skin  in  these  dermoids  is 
sensitive  and  that  it  possesses  tactile  sensibility. 

Dermoids  in  the  lower  section  of  the  orbito-nasal  fissure 
are  rare.  They  usually  protrude  in  the  naso-facial  sulcus,  and 
occasionally  possess  a  tooth  (Fig.  233). 


Fig.  233. — Dermoid  m  the  naso- 
facial  sulcus  containing  a  tooth. 
(After  Paul) 


Fig.  234.— A  translucent 
dermoid  at  the  bridge  of 
the  nose.  The  man  was 
30  years  of  age. 


Nasal  dermoids. — It  is  necessary  to  point  out  that  in 
addition  to  the  naso-facial  sulcus,  dermoids  occur  in  two  other 
situations  on  the  nose.  A  not  uncommon  position  is  the 
bridge  of  the  nose  (Fig.  234).  This  part  of  the  face  is  not 
traversed  by  a  fissure,  and  the  mode  by  which  such  a  dermoid 
arises  is  in  all  respects  identical  with  that  which  gives  rise  to 
cranial  dermoids. 

In  the  skull  of  an  early  embryo,  the  fronto-nasal  plate 
which  ultimately  forms  the  nose  consists  of  a  lamina  of 
hyalin  cartilage  covered  externally  with  skin  and  internally 


458 


BEBM0IB8 


witli  mucous  membrane.  After  the  third  month,  sections 
made  through  the  nasal  capsule,  immediately  anterior  to  the 
ethmoid,  show  that  the  skin  is  being  dissociated  from  the 
underlying  cartilage  by  bony  tissue,  which  eventually  becomes 
the  nasal  bones.  Ultimately  the  cartilage  disappears  as  a 
result  of  the  pressure  exercised  by  these  bones.  It  is  reason- 
able to  believe  that,  in  the  gradual  separation  of  the  skin 
from  the  cartilage  of  the  fronto-nasal  plate  by  the  intrusion 
of  the  nasal  bones,  small  portions  of  skin  or  epithelium 
become  sequestrated  and  eventually  develop  into  dermoids. 
This  explanation  is  more  fully  set  forth  in  the  next  section, 
on  dermoids  of  the  scalp  and  dura  mater. 


Fig.  23o.-Dernioid  recess  in  the  ^^S"    236.-Dennoid  recess  at  the  tip 

nose  of  an  adult.  °f  ^^^  ^°^«  °f  ^  ''^^^'^-     ^^he  hair 

is  represented  as  too  coarse.) 

Dermoids  near  the  tip  of  the  nose  are  the  consequence  of 
faulty  fusion  of  the  internasal  fissure,  and  usually  take  the 
form  of  narrow  skin-lined  recesses  furnished  with  hair,  which 
is  often  long  enough  to  sprout  beyond  the  recess  (Figs.  235 
and  286). 

Hair-lined  recesses  in  the  mid-line  of  the  nose  at  some 
point  between  the  lower  border  of  the  nasal  bone  and  the  tip 
of  the  nose  are  very  common,  but  they  rarely  call  for  treat- 
ment. The}?-  occur  far  more  frequently  in  men  than  in 
women.  In  their  mode  of  origin  and  characters  they  agree 
with  the  hair-lined  sinuses  known  as  postanal  dimples. 

A   much   rarer   anomaly    than    a   dermoid    is    excessive 


CRANIAL  DERMOIDS  45S 

coalescence  of  the  nasal  segment  of  the  orbito-nasal  fissure 
(Fig.  237). 

Dermoids  of  the  scalp  and  dura  mater. — The  common 
situations  for  dermoids  of  the  scalp  are  over  the  anterior  fon- 
tanelle  (bregma)  and  occipital  protuberance.  In  these  situa- 
tions they  are  occasionally  confounded  with  sebaceous  cysts 
or  with  meningoceles.  Dermoids  of  the  scalp  often  have  a 
thin  pedunculated  attachment  to  the  dura  mater,  the  pedicle 
traversing  a  hole  in  the  underlying  bone,  unless  the  cyst  is 
over  a  fontanel  le. 

The  term  "  wen "  used  to  be  applied  indifferently  to  se- 
baceous cysts  and  dermoids  of  the  scalp.     Sir  Astley  Cooper, 


Fig.  237. — Child  with  a  deformed  nose  due  to  excessive  coalescence  of  the  nasal 
section  of  the  orbito-nasal  fissure.     The  case  was  under  the  care  of  Mr.  Nicoll. 

in  his  essay  on "  Encysted  Tumours,"  even  included  orbital 
dermoids  among  wens.  In  describing  them,  he  writes : 
"  The  largest  size  I  have  known  them  acquire  has  been  that 
of  a  common-sized  coco-nut,  and  this  grew  upon  the  head  of 
a  man  named  Lake,  who  kept  the  house  called  the  '  Six 
Bells '  at  Dartford.  It  sprang  from  the  vertex,  and  gave  him 
a  most  grotesque  appearance,  for  when  his  hat  was  put  on, 
it  was  placed  upon  the  tumour  and  scarcely  reached  his 
head.  The  cyst  is  in  the  collection  at  St.  Thomas's  Hospital, 
also  a  cast  of  his  head  taken  just  prior  to  the  operation  " 
(Fig.  238). 


460 


DERMOIDS 


The  cyst,  wiiich  is  probably  the  largest  dermoid  of  the 
scalp  on  record,  contains  a  number  of  round  balls,  some 
having  a  diameter  of  1  cm.  These  consist  of  epithelial  cells 
mixed  with  fat.     (See  also  Sibthorpe  and  Marsh.) 

Arnott  published  the  details  of  an  instructive  case  of  a 
dermoid  situated  over  the  anterior  fontanelle  in  an  infant  a 


Fig.  238. — Head  of  the  man  Lake  witli  a  large  dermoid  over  the  bregma. 
{From  a  cast  in  the  Museum,  St.  Thomases  Hospital.) 

few  days  old.  The  tumour  exactly  resembled  a  meningocele, 
"  rising  and  falling  with  regular  pulsation,  and  swelling  when 
the  child  coughed  " ;  the  resemblance  was  so  strong  that  it 
was  regarded  as  a  meningocele.  A  few  weeks  later  the  child 
died  from  broncho-pneumonia,  and  the  cyst  was  found  to  be 
a  dermoid.  The  specimen  is  preserved  at  St.  Thomas's 
Hospital.     (See  also  Giraldes.) 

Dermoids  in  the  neighbourhood  of  the  occipital  protuber- 
ance (inion)  may  lie  on  the  inner  aspect  of  the  occipital 
bone,  and   are  nearly  always  in  relation  with  the  tentorium 


CRANIAL  DERMOIDS  461 

cerebelli.  Examples  have  been  described  by  Turner,  Ogle, 
Pearson,  Irvine,  and  Lannelongue.  They  occurred  in  children, 
and  in  Ogle's  case  there  was  defective  development  of  the 
squamous  portion  of  the  occipital  bone.  In  Lannelongue's 
patient,  a  girl  7  years  old,  the  dermoid  had  attained  the 
size  of  an  orange;  it  produced  marked  symptoms,  such  as 
paralysis,  amaurosis  and  coma,  ending  in  death. 

Although  at  first  sight  a  dermoid  connected  with  the 
dura  mater  and  projecting  into  the  brain  seems  to  -violate 
all  embryological  rules,  nevertheless,  when  we  view  this 
membrane  from  a  morphological  standpoint  the  strangeness 
vanishes  and  a  satisfactory  explanation  is  forthcoming. 

Morphologically  considered,  the  bony  framework  of  the 
skull  is  an  additional  element  to  the  primitive  cranium, 
which  is  represented  by  the  dura  mater,  and,  as  I  have  else- 
where endeavoured  -to  show,  the  term  extracranial  should 
strictly  apply  to  all  tissues  outside  the  dura  mater.  In  sur- 
gical practice  we  find  it  convenient  to  regard  the  bones  as 
the  boundary  of  the  skull,  but  morphologically  this  is  in- 
accurate ;  the  skull-bones  are  secondary  cranial  elements. 
Early  in  embryonic  life  the  dura  mater  and  skin  are  in  con- 
tact; gradually  the  base  and  portions  of  the  side- walls  of  the 
membranous  cranium  chondrify,  thus  separating  the  skin 
from  the  dura  mater.  In  the  vault  of  the  skull,  bone 
develops  between  the  dura  mater  and  its  cutaneous  cap,  but 
the  skin  and  dura  mater  remain  in  contact  along  the  various 
sutures  even  for  a  year  or  more  after  birth.  This  relation 
of  the  dura  mater  and  skin  persists  longest  in  the  region  of 
the  anterior  fontanelle  (bregma)  and  the  neighbourhood  of 
the  inion.  Should  the  skin  be  imperfectly  separated,  or  a 
portion  remain  persistently  adherent  to  the  dura  mater,  it 
would  act  precisely  as  a  tumour-germ  and  give  rise  to  a 
dermoid.  Such  a  tumour  may  retain  its  original  attach- 
ment to  the  dura  mater,  and  its  pedicle  become  surrounded 
by  bone;  the  dermoid  would  lie  outside  the  bone,  but  be 
lodged  in  a  depression  on  its  surface,  with  an  aperture  trans- 
mitting its  pedicle.  On  the  other  hand,  the  tumour  may 
become  separated  from  the  skin  by  bone ;  it  would  then  pro- 
ject on  the  inner  surface,  or  between  the  layers  of  the  dura 
mater.     If  this  view  of  the  origin  of  dermoids  of  the  scalp  be 


462  DERMOIDS 

admitted,  we  must  then  modify  our  teacliing,  and  say  that 
the  depressions  in  which  dermoids  of  the  cranium  are  lodged 
arise  as  imperfections  in  the  developmental  process,  and 
are  not  due  to  absorption  induced  by  pressure ;  further,  the 
fibrous  connexion  of  such  dermoids  with  the  underlying 
dura  mater  is  primary,  not  accidental. 

A  study  of  the  development  of  the  tentorium  cerebelli  will 
demonstrate  that  it  is  composed  of  two  folds  of  dura  mater, 
and  it  arises  as  an  infolding  or  crease  in  this  membrane,  caused 
by  the  rapid  backward  extension  of  the  developing  cerebrum. 
The  opposed  surfaces  of  the  tentorial  lamellae,  like  the  outer 
surface  of  the  dura  mater  in  relation  with  the  cerebrum,  were 
originally  in  contact  with  the  skin,  and  as  the  posterior  margins 
of  the  bay  or  recess  formed  by  the  crease  in  the  dura  mater 
come  together,  a  portion  of  the  skin  may  become  nipped  or 
even  sequestrated  between  the  layers  of  the  tentorium ;  this, 
preserving  its  vitality,  and  in  some  cases  its  cutaneous 
connexions,  may  ultimately  give  rise  to  an  intracranial 
dermoid. 

IMPLANTATION-CYSTS 

These  small  cysts  should  not  be  included  among  tumours, 
but  their  consideration  is  imperative  in  connexion  with 
sequestration  dermoids,  for  they  furnish  valuable  evidence 
that  dermoids  of  this  genus  arise  from  "  rests,"  the  result  of 
faulty  coalescence. 

These  cysts  are  caused  by  the  accidental  implantation  of 
portions  of  skin,  epithelium,  or  hair-bulbs  in  the  underlying 
connective  tissues.  The  transplanted  tissue  acts  in  many 
instances  as  a  graft,  and  forms  a  small  cyst.  Implantation- 
cysts  have  received  a  variety  of  names,  such  as  dermal  cysts, 
traumatic  dermoids,  sebaceous  cysts  of  the  fingers,  etc. 
(Fig.  239). 

They  are  common  on  the  fingers,  the  cornea,  and  the  iris, 
but  may  arise  on  any  part  of  the  skin.  They  have  been  ob- 
served by  many  surgeons,  and  careful  accounts  have  been 
written,  especially  by  Polaillon,  Le  Fort,  and  Garre. 

Implantation-cysts  vary  much  in  size ;  some  are  scarcely 
as  big  as  a  split  pea,  others  may  be  as  large  as  a  ripe  cherry. 
In  many  the  microscopic  characters  "  a]3pear  as  if  a  piece  of 


IMPLANTATION- CYSTS  463 

the  skin  covering  the  pulp  of  the  finger  had  been  inverted  " 
(Shattock).  In  others  the  implanted  epidermis  seems  to  have 
been  shed  in  layers,  so  that  on  section  the  interior  of  the  cyst 
is  occupied  by  epithelial  laminae.  When  these  cysts  occur  on 
the  scalp,  the  interior  contains  hair. 

Implantation- cysts  are  caused  in  a  variety  of  ways,  such 
as  punctures  by  awls,  forks,  needles,  thorns,  glass,  etc. ;  also 
accidental  wounds  by  knives,  incisions  by  scalpels,  bites,  and 
lacerations. 

These  cases  are  of  interest,  for  they  serve  to  throw  light  on 
some  cysts,  containing  hair  and  wool,  preserved  in  the  museum 


TV""-''''-^  .- 


Fig.  239. — Implantation-cyst  of  the  finger. 

of  the  Royal  College  of  Surgeons.  Two  of  the  cysts  are  from 
sheep,  and  contain  wool  embedded  in  fatty  matter.  Unfor- 
tunately, the  catalogue  affords  no  information  as  to  the  region 
of  the  body  whence  they  were  removed.  The  third  and 
fourth  specimens  were  removed  from  the  shoulder  of  a  cow 
that  had  six  legs.  The  cysts  contain  light  hair,  fatty  and 
calcareous  matter.  These  four  specimens  are  Hunterian. 
The  iifth  specimen  was  removed  from  beneath  the  integu- 
ments of  the  shoulder  of  an  ox.  It  contained  slender  black 
hairs,  resembling  those  on  the  skin  of  the  animal,  mixed  with 
fat.  I  once  obtained  a  good  example  of  an  implantation-cyst 
from  the  axilla  of  an  ox.  The  cyst  was  as  large  as  a  billiard- 
ball,  and  in  structure  resembled  a  piece  of  inverted  skin. 
Fortunately,  these  cysts  can  be  explained  on  the  same  lines  as 
similar  cysts  of  the  fingers  in  man.  The  sticks  used  by 
cattle-drovers  are  armed  at  the  end  with  a  sharp  iron  spike, 
2-5  cm.  (1")  long,  with  which  they  "prod"  the  beasts,  often  very 
severely.  It  may  be  assumed  that  punctures  produced  with 
such  an  instrument  may  lead  to  the  deposition  of  dermal 
grafts    beneath    the    skin,    which    may    give    rise    to    cysts 


464  DERMOIDS 

in  the  same  way  as  punctured  wounds  in  the  sldn  of  men 
and  women.  Punctured  wounds  in  sheep  and  oxen  may  also 
be  caused  by  projecting  nails,  iron  spikes,  tenter-hooks,  and 
the  hke. 

The  opinion  that  cysts  may  arise  in  the  subcutaneous 
tissues  by  implantation  receives  the  strongest  jDossible  con- 
firmation from  what  we  know  of  similar  cysts  of  the  Ms  and 
cornea  associated  with  mechanical  injury. 

Iritic  cysts. — Cysts  of  the  iris  are  of  comparative  rarity, 
generally  appearing  as  transparent  vesicles  situated  on  its 
anterior  surface.  As  a  rule  they  are  sessile,  but  occasion- 
ally possess  a  pedicle.  The  contents  may  be  opaque,  but  in 
exceptional  cases  they  have  been  filled  Avith  sebaceous 
material,  such  as  fills  the  cavities  of  dermoids. 

Hulke  (1869)  collected  some  valuable  facts  in  relation  to 
such  cysts,  and  states  that  in  fifteen  out  of  nineteen  cases,  as 
well  as  in  two  reported  by  himself,  there  was  distinct  history 
of  antecedent  mechanical  injury. 

Numerous  instances  are  known  in  Avhich  eyelashes,  some- 
times as  many  as  six,  have  been  implanted  on  the  iris  by 
foreign  bodies  penetrating  the  cornea,  such  as  knives,  needles, 
foils,  and  swords.  Barry  Sullivan,  whilst  acting  as  Richard  III., 
received  during  the  famous  combat  (Act  v.,  Scene  4),  a  wound 
in  the  eye  from  his  opponent's  sword.  Subsequently  a  cyst 
containing  an  eyelash  grew  from  the  iris.  Similar  cysts  have 
been  produced  in  the  eyes  of  rabbits  by  the  artificial  introduc- 
tion of  eyelashes  and  epithelium  into  the  anterior  chamber. 

Corneal  cysts. — In  addition  to  the  evidence  furnished 
by  implantation-cysts  of  the  iris,  we  know  that  similar  cysts 
occur  in  the  cornea.  Treacher  Collins  has  investigated  this 
matter,  and  has  published  some  valuable  researches  in  which 
he  has  succeeded  in  demonstrating  that  after  gunshot  injuries 
of  the  eyeball,  blows  from  tip-cats,  and  incisions  made  for  the 
extraction  of  cataracts,  cysts,  usually  of  small  size,  are  liable 
to  form  in  the  cornea  near  the  seat  of  injury.  In  some  of  the 
specimens  the  cysts  may  be  very  large  and  conspicuous ; 
when  examined  microscopically,  their  inner  walls  are  found 
lined  with  layers  of  ceUs  identical  with  those  covering  the 
anterior  surface  of  the  conjunctiva.  The  structure  of  these 
cysts,   taken   in   conjunction   with   the  antecedent   injuries. 


SEQUESTRATION  DERMOIDS  465 

tlioroughly  supports  the  view  that  they  arise  from  conjunc- 
tival epithehum  transplanted  into  the  deep  tissues  of  the 
cornea, 

Arnott,  Henry,  "  Dermoid  Cyst  o£  the  Scalp  simulating  Meningocele." — Trans. 

Path.  Soa.,  1874,  xxv.  228. 
Ashby,  H.,  and  Wright,  G.  A.,  "  Diseases  of  Children,  Medical  and  Surgical," 

1899,  p.  770.     [Dermoid  containing  tooth.] 

Bland-Subton,  J.,  "A  Critical  Study  in  Cranial  Morphology." — Juurn.  of  Anat. 

and  Phys.,  1888,  xxii.  28. 
Collins,    E.   Treacher,    "The   Anatomy   and   Pathology   of   the   Eye,"    1896,. 

pp.  77,  78. 
le  Fort,  "  Kyste  du   Petit   Doigt.      Eecidive   apres   une   premiere  ponction ; 

guerison  par  la  compression.     Analyse   chimique   du   liquide." — Bull,  et 

3Imi.  de  la  Soc.  Chir.,  1881,  vii.  547. 
Garre,  C,  "  Ueber  traumatische  Epithelcyste  der  Finger." — Beit.  z.  Min.  Cliir. 

(Bruns),  1894,  xi.  524. 
Giraldes,  J.,  "  Le9ons  Oliniques  sur  les  Maladies  Chirurgicales  des  Enfants," 

1869,  342. 
Hosch,  Fr.,    "  Experimentelle   Studien   liber  Iriscysten." — Virchow's  Arch,  f 

-path.  Anat.,  1885,  xcix.  449. 
Hulke,  J.  W.,  "  On  Cases  of  Cysts  of  the  Iris." — Roy.  Bond.  Ophthal.  Hosp. 

Repts.,  1869,  vi.  12. 
Irvine,  J.  Pearson,  "  Dermoid  Cyst  of  the  Brain." — Trans.  Path.  Soc,  1879, 

XXX.  195. 
Lannelongue  et  Menard,  V.,  "Kystes  Extra-crauiens  de  I'lnion." — -"Affections 

Congenitales,"  1891,  i.  50,  51. 
Marsh,  F.,  "  Dermoid    Cyst  simulating  a  Meningocele." — Brit.  Med.  Journ., 

1900,  i.  443. 

Ogle,  J.  W.,  "Congenital  Cysts  containing  hair  and  sebaceous  material,  or 
communicating  with  the  cranial  sinuses  [Morbid  growths  of  the  brain, 
spinal  cord,  etc.]  " — Brit,  and  For.  Med.- Chir.  Bev.,  1865,  xxxvi.  208. 

Paul,  F.  T.,"  Dermoid  Tumour  of  the  Face,  carrying  Teeth." — Trans.  Path.  Soc, 
1894,  xlv.  148. 

Polaillon,  "  Doigt  (Pathologic)  ;  Kystes  Dermoides." — Die.  Ency.  des  Sci. 
Med.,  1884  (lere  serie),  xxx.  281. 

Sibthorpe,  "  Congenital  Sebaceous  Cyst." — Brit.  Med.  Journ.,  1888,  i.  350. 

Turner,  William,  "  Case  of  Intracranial  Cyst  containing  Hair ;  also  a  Case 
illustrating  the  physiological  action  of  iodine." — St.  Bart's  Uoi-i).  Bepts., 
1866,  ii.  62. 

Walther,  C,  "  Kyste  de  I'lnion."— Prme  Mkl.,  1895,  pp.  123-126. 


2  E 


CHAPTER  XLVI 

TUBULO  -  DERMOIDS 

LINGUAL  DERMOIDS-MEDIAN  CERVICAL  FISTUL^E— 
ACCESSARY  THYROID  GLANDS 

There  exist  in  the  human  embryo  certain  canals  and  passages 
many  of  which  normally  disappear  before  birth.  Among 
these  obsolete  canals  there  are  three  that  require  especial 
consideration  in  connexion  with  dermoids — viz.  the  thyro- 
glossal  duct,  the  postanal  gut,  and  the  branchial  clefts.  The 
remainder  will  be  considered  in  the  section  devoted  to  cysts. 

The  thyro-glossal  duct. — The  thyroid  gland  of  man 
consists  of  two  lobes  united  by  a  narrower  portion  or  isth- 
mus. His  maintains  that  the  three  parts  of  this  gland  arise 
separately.  The  lateral  lobes  originate  independently  ot 
the  isthmus,  which  is  derived  from  a  median  tubular  out- 
growth from  the  ventral  wall  of  the  embryonic  pharynx, 
known  as  the  thyro-glossal  duct.  This  duct  bifurcates  at  its 
lower  end  and  gives  rise  to  the  thyroid  isthmus,  which  fuses 
with  the  lateral  thyroid  rudiments,  and  assists  in  forming  the 
lobes  of  the  gland.  Originally  the  duct  extends  as  far  upwards 
(forwards  in  the  embryo)  as  the  dorsum  of  the  tongue,  but  as 
the  body  of  the  hyoid  bone  develops,  the  duct  becomes 
divided  into  an  upper  segment,  the  lingual  duct,  and  a  lower 
portion,  the  thyroid  duct.  In  the  ordinary  course  of  develop- 
ment these  ducts  disappear,  but  in  some  cases  they  persist 
and  attain  a  fair  size.  Thus  the  central  part  of  the  thjroid 
may  be  regarded  as  the  remnant  of  a  secreting  gland  provided 
with  a  duct  Avhich  conveyed  the  products  of  the  gland  into 
the  pharynx. 

There  are  at  least  three  abnormalities  which  appear  to 
be  associated  with  vagaries  of  the  thyro-glossal  duct:  (1) 
lingual  dermoids,  (2)  median  cervical  fistulse,  (3)  accessary 
thyroids. 

466 


TUSULO-BERMOIDS 


467 


1.  Lingual  dermoids. — Dermoids  arising  in  the  tongue 
have  been  many  times  observed  and  reported  as  sebaceous 
cysts.  Barker,  however,  pubhshed  a  clear  account  of  their 
nature,  and  showed  them  to  be  true  dermoids.  Subsequent 
research  has  proved  that  those  dermoids  which  occupy  a 
central  jDosition  in  the  tongue  between  the  genio-hyo-giossi 
muscles  arise  in  the  lingual  duct.  When  fully  developed  this 
duct  extends  from  the  foramen  csecum  to  the  posterior  surface 
of  the  basi-hyoid.     Occasionally  the  duct  is  so  large  that  a 


Fig.  240. — Large  lingual  dermoid,  protruding  from  the  mouth.     {Gray.) 

probe  may  be  introduced  into  it  from  the  foramen  csecum. 
The  duct  lies  exactly  between  the  genio-hyo-glossi  muscles, 
and  is  not  infrequently  replaced  by  a  solid  fibrous  cord.  It 
is  easy  to  understand  that  if  a  persistent  duct  should  have  its 
upper  end  obstructed  or  obliterated,  the  continual  shedding 
of  the  epithelium  which  lines  it  and  the  accumulation  of 
sebum  from  the  glands  would  convert  it  into  a  cyst,  which  in 
due  course  would  assume  such  a  size  as  to  come  within  the 
range  of  clinical  observation. 

The  walls  of  lingual   dermoids  are  composed  of  fibrous 
tissue,  lined  internally  with  squamous  epithelium  beset  with 


468 


DERMOIDS 


hair  and  sometimes  with  glands.  The  contents  of  these  cysts 
are  epithehal  cells,  hair,  sebum,  and  cholesterin.  Should 
the  cyst  burst,  then  it  would  suppurate  and  become   very 


disagreeable. 
Lingual 


dermoids  are  occasionally  sufficiently  large  to 
attract  attention  in  infants,  but  most  of  the  examples  come 
under  notice  in  adolescents  (Fig.  240). 

In  addition  to  the  common  variety  of  dermoid,  the  tongue 
is  occasionally  occupied  by  tumours  which  in  structure  re- 


Fig.  241.— Median  cei-vical  fistula  in  a  man  aged  23  years.     The  fistula  appeared 
when  he  was  3  years  old. 

semble  the  thyroid  gland.  They  occur  in  the  neighbourhood 
of  the  foramen  caecum,  between  the  genio-hyo-glossi  muscles. 
Bernays  has  given  a  careful  description  of  such  a  tumour 
which  he  removed  from  the  tongue  of  a  girl  17  years  of  age, 
and  associated  the  tumour  with  the  lingual  duct  {also  Wolff, 
Warren,  and  Mcllraith). 

2.  Median  cervical  fistulae. — These  openings  occur  singly, 
and  open  at  some  point  in  the  middle  line  of  the  neck  between 
the  hyoid  bone  and  the  top  of  the  sternum.     The  common 


MEDIAN  GEBVIGAL  FISTULA 


469 


situation  is  a  little  below  the  level  of  tlie  cricoid  cartilage. 
Median  cervical  fistulse  differ  from  those  arising  in  connexion 
with  branchial  clefts  in  the  fact  that  they  are  never  congenital; 
they  may  occur  soon  after  birth  or  make  their  appearance  as- 
late  as  the  fourteenth  year, 

Cusset  described  a  median  cervical  fistula  in  1877,  but 


LE\f,h/.  FECIT. 


Fig.  242. — Section  of  a  persistent  thyroid  duct. 

A  represents  the  duct  of  natural  size.     The  lowest  drawing  shows  the  epithelium 

more  highly  magnified. 

Raymond  Johnson  clearly  pointed  out  that  median  cervical 
fistulse  are  preceded  by  a  swelling  in  the  middle  line  of  the 
neck  which  either  ruptures  or  is  opened  by  the  surgeon ;  this 
leaves  a  sinus  which  never  closes. 

The  following  is  a  common  example  of  a  median  cervical 
fistula.     The  patient  presented  in  the  lower  third  of  the  neck 


470 


DERMOIDS 


a  depression,  the  floor  of  wliicli  was  puckered  and  scar-like 
(Fig.  241).  At  the  upper  part  of  this  bay  or  recess  there  was 
a  rounded  opening  from  which  clear  mucus  exuded.  An 
ordinary  probe  introduced  into  this  hole  easily  passed  upwards 
in  the  middle  line  directly  beneath  the  skin,  to  stop  at  the 
middle  of  the  lower  border  of  the  basi-hyal.  The  opening 
in  the  neck  had  existed  as  long  as  he  could  remember,  but 
his  parents  told  him  that  it  appeared  when  he  was  about 


Fig.  243. — Median  cervical  fistula  associated  with  a  persistent  thyroid  duct. 

three  years  old.  Ordinarily  the  fistula  caused  no  incon- 
venience, but  during  the  past  two  years  it  seemed  subject  to 
catarrh,  and  the  excessive  flow  of  mucus  caused  him  much 
inconvenience,  so  it  was  dissected  out. 

The  duct  was  lined  with  columnar  ciliated  epithelium. 
The  tissue  forming  its  walls  resembled  atrophied  th3^roid 
tissue ;  here  and  there  (Fig.  242)  isolated  channels  could  be 
seen  in  section  lined  with  columnar  epithelium. 


MEDIAN  GERVIGAL  FISTULA 


471 


Occasionally  a  persistent  thyroid  duct  is  so  large  as  to 
form  a  conspicuous  vertical  ridge  in  the  middle  of  the  neck 
in  association  with  a  median  cervical  fistula  (Fig.  243). 

Thus  a  median  cervical  fistula  is  in  striking  contrast  to 
branchial  fistulse,  which  are  always  lateral  in  position  and  in 
close  relation  with  the  anterior  border  of  the  sterno-mastoid 
inuscle,  and  are  always  congenital. 

Our  knowledge  of  the  nature  of  these  fistulas  was  not  very 
satisfactory  until  the  publication  of  an  able  paper  by  Marshall, 
detailing  the  anatomy  of  the  parts  in  the  neighbourhood  of 
the  hyoid  bone  of  a  child  5  years  old,  who  had  a  median 


Foramen  caecum. 


Hyoid  boae. 


Thyroid  cartilage. 


Pyramid  of 
thyroid  gland. 


Abscess  sac. 


Tliyroid  gland 


Trachea. 


Fig.  241. — Diagram  to  show  the  relation  of  parts  in  a  case  of  median  cervical  fistula. 
{After  C.  F.  Marshall.) 

sinus  in  the  neck.  The  patient  was  admitted  into  a  hospital 
for  the  purpose  of  having  the  duct  excised;  it  contracted 
diphtheria  and  died  before  the  operation  could  be  performed. 
In  the  median  line  of  the  neck,  2-5  cm.  (1")  above  the 
sternum,  there  was  a  sinus,  which,  during  life,  discharged  a 
small  quantity  of  mucous  fluid.  From  this  opening  a  hard 
cord  could  be  felt  extending  up  to  the  hyoid  bone.  On 
dissecting  the  front  of  the  neck  this  cord  was  found  to  be 


472  DERMOIDS 

tubular  and  patent  up  to  within  1  era.  of  its  termination ;  the 
upper  end  was  firmly  attached  to  the  hyoid  bone,  the  lower 
end  dilated  into  a  thin-walled  sac  opening  on  to  the  surface 
of  the  skin.  The  sac  and  tube  lay  between  the  skin  and  the 
anterior  layer  of  the  deep  cervical  fascia ;  at  no  place  was 
there  any  connexion  with  the  thyroid  gland. 

On  dividing  the  hyoid  bone  the  tube  could  be  traced  as 
an  ill-defined  fibrous  cord  on  to  its  dorsal  surface,  to  which  it 
was  closely  attached,  and  through  the  substance  of  the  tongue 
to  the  foramen  caecum.  About  2  cm.  from  the  foramen  it 
again  became  patent,  and  continued  so  up  to  the  surface  of 
the  tongue.  The  canal  was  thus  open  at  both  ends,  but 
impervious  in  the  middle. 

On  further  dissection  a  lobus  pyramidalis  was  found 
connected  with  the  left  side  of  the  thyroid  isthmus,  its  upper 
end  being  united  to  the  median  fibrous  cord  at  the  same  place 
as  the  above-mentioned  canal  In  other  words,  the  fibrous 
cord  behind  the  hyoid  bone  was  continuous  both  with  the 
pyramidal  lobe  of  the  thyroid  and  with  the  tube  leading  to 
the  superficial  sinus  (Fig.  244). 

The  relations  of  the  parts  indicate  the  probable  mode  by 
which  these  median  fistula  arise  ;  they  are  probably  retention- 
cysts  formed  in  a  persistent  thyroid  duct,  and  the  pressure 
of  the  cyst  ultimately  causes  the  skin  to  yield  and  form 
a  sinus. 

3.  Accessary  thyroids. — The  consideration  of  accessary 
thyroids  naturally  follows  on  the  description  of  median 
cervical  fistulse,  for  there  is  good  reason  to  believe  that  the 
thyroid  duct  is  the  source  of  some  of  these  bodies.  They 
have  long  been  known  (Albers  and  Virchow),  and  in  recent 
years  have  been  carefully  studied.  They  occur  most  frequently 
in  the  neighbourhood  of  the  hyoid  bone  and  in  the  hollow 
formed  by  the  two  lobes  of  the  thyroid  gland.  As  the  thyro- 
glossal  duct  is  directly  associated  with  the  formation  of  the 
thyroid  body,  and  as  median  accessary  thyroids  are  found 
directly  in  its  track  from  the  hyoid  to  the  thyroid  isthmus,  it 
is  not  unreasonable  to  regard  these  little  bodies  as  remnants 
of  this  remarkable  tube. 

Accessary  thyroids  occasionally  arise  in  connexion  with 
the  germs  of  the  lateral  lobes  of  the  thyroid :  these  are  most 


ACCESS  ART  THYROIDS  473 

commonly  found  in  the  neighbourhood  of  the  greater  cornu 
of  the  hyoid. 

Accessary  thyroids  are  in  the  main  innocent  structures, 
but  occasionally  they  give  rise  to  troublesome  tumours.  It  is 
well  known  that  when  the  thyroid  body  becomes  goitrous,  and 
accessary  thyroids  co-exist,  the  latter  will  enlarge  and  become, 
in  fact,  goitrous.  Apart  from  this,  accessary  thyroids  will 
enlarge  on  their  own  account  and  produce  tumours  which 
closely  simulate  unilateral  enlargement  of  the  thyroid,  and 
occasionally  give  rise  to  bronchoceles  of  moderate  dimensions. 

Albers,  "  Atlas  der  pathologischen  Auatomie,"  1847,  Abth.  ii.,  Taf.  xxv., 
xxvi.  and  xxix. 

Barker,  A.  E.,  "  Sebaceous  or  Dermoid  Cyst  of  the  Tongue  ;  removal  by  sub- 
mental incision  ;  cure." — Trans.  Clin.  Soc,  1883,  xvi.  215. 

Barker,  A.  E.,  "  Two  Cases  of  Dermoid  Cyst  in  connection  with  the  Tongue." — 
Trans.  Clin.  Soc,  1891,  xxiv.  68  (p.  70,  "  Case  of  Dr.  Wellington  Gray  "). 

Bernays,  A.  C. — St.  Louis  Med.  and  Surg.  Journ.,  Iv.  201. 

Johnson,  Raymond,  "  Two  Cases  of  Persistent  Thyroid  Dact." — Trans.  Path. 
Soc,  1890,  sli.  325. 

Mcllraith,  C.  H.,  "  Notes  on  a  Case  of  Accessary  Thyroid  Gland  projecting  into 

the  Mouth."— i^rJ!^.  Med.  Jonrn.,  1894,  ii.  1234. 
Marshall,  C.  F.,  "  The  Thyro-Glossal  Duct  or  '  Canal  of  His.' " — Journ.  Anat.  and 

Phys.,  1892,  xxvi.  94. 

Warren,  J.  Collins,  "  A  Case  of  Enlarged  Accessary  Thyroid  Gland  at  the 
Base  of  the  Tongue." — Amer.  Journ.  Med.  Sci.,  1892,  civ.  377. 

Wolf,  R.,  "  Ein  Fall  von  accessorischer  Schilddruse." —  Arch.  f.  klin.  Chir. 
(Langenbeck),  1889,  xxxix.  224. 


CHAPTER  XLVII 
CERVICAL  FISTULA,  DERMOIDS  AND  AURICLES 

CERVICAL  FISTULiE  AND   AURICLES 

Cervical  fistulae.  —  It  is  not  imcommon  to  find  in  the 
neck,  at  some  point  along  the  anterior  border  of  the  sterno- 
mastoid  muscle,  a  small  orifice  in  the  skin  capable  of  admitting 
a  bristle  or  a  fine  probe.  These  congenital  openings  are 
known  as  cervical  or  branchial  fistula3,  and 
they  are  probably  persistent  representatives 
of  the  branchial  fissures  which  were  dis- 
covered in  the  embryos  of  pigs,  horses, 
and  man  by  Rathke  in  1825  (Fig.  245). 
Congenital  fistulous  openings  in  the  side 
Fig  245  —Early  ^^  ^^^  nock  wcro  obscrved  many  years  be- 
human  embryo,  forc  Rathke's  embryologic  discovery,  and 
shoM-iug  the  gill-  Heusinger  (1854)  was  the  first  clearly  to 
recognize  the  relationship  of  these  fistulse 
with  the  branchial  clefts. 

In  the  majority  of  cases  these  openings  terminate  as 
sinuses,  but  exceptionally  they  pass  deeply  among  the  struc- 
tures of  the  neck  and  terminate  on  the  wall  of  the  pharynx  or 
open  into  the  j)haryngeal  cavity.  One,  two,  or  three  orifices 
may  be  present  in  the  same  child,  and  they  exhibit  a  great 
tendency  to  be  bilateral,  to  affect  several  members  of  the  same 
family,  and  to  be  transmitted  to  several  generations.  These 
sinuses  or  canals,  which  may  vary  in  length  from  2  to  5  cm.,  are 
lined  by  mucous  membrane,  sometimes  with  ciliated  epithelium, 
or  by  skin  containing  sebaceous  glands.  The  lining  membrane 
of  the  canal  usually  secretes  a  thin  mucous  fluid,  which  may 
become  increased  during  catarrhal  conditions  of  the  respiratory 
passages.  Occasionally  the  canal  inflames  and  an  abscess 
results,  which  ma}^  give  rise  to  considerable  pain  and  difficulty 
in  deglutition.     The  external  orifice  of  a  branchial  fistula  may 

474 


GEBVIOAL  FISTULJ^  475 

be  indicated  by  a  tag  of  skin  containing  a  piece  of  3'ellow 
elastic  cartilage,  and  these  protuberances  are  commonly 
known  as  cervical  auricles. 

The  external  orifices  of  the  sinuses  vary  in  j)osition,  but 
they  are  always  situated  along  the  anterior  border  of  the 
sterno-mastoid  muscle.  The  common  situation  is  a  spot  in 
line  with  the  angle  of  the  jaw,  but  they  may  open  anywhere 
along  the  line  of  the  muscle  from  the  mastoid  process  to  the 
sterno- clavicular  articulation.  When  the  fistula  extends  to 
the  pharynx,  the  duct  keeps  a  constant  course  and  passes 
between  the  fork  of  the  carotid  artery,  above  the  sling  of  the 
superior  laryngeal  nerve,  and  terminates  in  the  sacculus 
pyriformis. 

Heuter  refers  to  a  young  man  who  had  a  cervical  fistula 
and  "  wished  to  become  a  trumpeter  " ;  he  dissected  out  the 
fistulous  tract,  "  following  it  between  the  two  carotids  to  the 
pharynx." 

A  lad  of  15  years  under  my  observation  complained  of  a 
mucous  discharge  which  soiled  his  collar  occasionally ;  fluid 
when  swallowed  leaked  through.  I  dissected  out  the  duct  and 
found  that  it  passed  through  the  fork  of  the  carotid  artery. 

Heusinger  held  the  opinion  that  some  pharyngeal  diver- 
ticula arise  as  distensions  of  the  persistent  pharyngeal  seg- 
ments of  branchial  clefts.  Morrison  Watson  recorded  a  case 
in  which  he  made  a  careful  dissection  of  such  a  diverticulum. 
The  parts  are  shown  in  Fig.  246,  and  in  the  description  it 
is  stated  that  a  tube  terminating  inferiorly  in  a  cul-de-sac 
containing  a  large  quantity  of  grumous  material  was  found 
extending  from  the  pharynx,  immediately  behind  the  tonsils, 
to  the  interclavicular  notch.  This  tube  possessed  muscular 
walls,  and  in  the  deep  part  of  its  course  passed  between  the 
fork  of  the  carotids  and  over  the  loop  of  the  superior  laryngeal 
nerve ;  its  lower  part  was  parallel  with  the  anterior  border  of 
the  sterno-mastoid  muscle ;  it  rested  on  the  sterno-hyoid  and 
sterno-thyroid  muscles.  It  communicated  with  the  pharynx 
by  means  of  a  slit-like  opening,  not  more  than  3  mm.  in 
length,  the  margins  of  which  were  so  closely  in  contact  that 
the  entry  of  solid  particles  into  it  from  the  mouth  must  have 
been  prevented.  The  diverticulum  itself  increased  in  calibre 
from   above  downwards,  so  that  whilst  at  the   upper  end   a 


476 


DERMOIDS 


crow-quill  could  'witli  difficult}^  be  introduced,  at  the  lower 
a  pencil  could  readily  be  passed  along  the  lumen  of  the  tube. 

It  is  further  noteworthy  that  the  pharyngeal  orifice  was 
situated  between  the  lower  jaw  and  the  stylo-hyoid  ligament. 
Its  point  of  departure  from  the  pharynx  corresponds  to  the 
supratonsillar  fossa.  The  muscle-fibres  were,  for  the  most 
part,  red  and  striated,  and  the  mucous  lining  resembled  that 
of  the  ffisophagus. 

It  has  long  been  suspected  that  the   so-called  sebaceous 


Fig.  246. — Pharyngeal  diverticulum.     {After  Morrison  Watson.) 

cj'sts  which  arise  in  the  neck  below  the  deep  fascia  take 
origin  in  unobhterated  segments  of  branchial  clefts.  Such  a 
C3^st  does  not  necessarily  contain  grease  or  hair :  it  may  be 
filled  with  mucus.  The  walls  of  cervical  fistulEe  are  covered 
with  epithelium  of  various  kinds,  which  in  some  is  ciliated  and 
in  others  squamous,  and  so  forth.  Mucous  cysts  in  the  side 
of  the  neck  arising  in  persistent  branchial  clefts  must  not 
be  confused  with  lyrnphatic  cysts  (see  p.  164),  or  with  der- 
moids associated  with  the  thjTo-glossal  duct  {see  p.  466). 
Rowley  has  described  and  figured  a  small  tumour  which 


GEBVIGAL  AURIGLE8 


477 


he  found  in  a  frog,  Rana  temporaria,  posteriorly  to  the  angle 
of  the  jaw.  This  on  microscopic  examination  was  found  to 
be  made  of  concentric  laminae  of  epidermis  and  dermis.  The 
structure  and  position  of  the  tumour  led  Rowley  to  regard 
it  as  a  dermoid  due  to  the  inclusion  of  epithelium  during  the 
occlusion  of  a  gill- cleft  in  larval  life. 

Cervical  auricles.  —  In  describing  branchial  fistulse 
(p.  475)  it  was  mentioned  that  the  cutaneous  orifices  are 
in  some  cases  surmounted  by  tags  of  skin.  These  tags, 
or  processes,  sometimes  occur  unassociated  with  fistulse,  but 


Fig.  247.— Cervical  auricles  in  a  child. 

always  in  situations  where  fistulse,  when  present,  open  on 
the  skin.  Usually  they  are  short,  in  some  cases  mere 
nodules,  but  in  others  form  prominences  2  to  3  cm.  in  height. 
These  processes  have  been  described  under  a  variety  of 
names,  and  classed  among  tumours,  but  at  the  present  time 
they  are  commonly  known  as  cervical  auricles. 

Like  branchial  fistulas,  they  are  always  congenital,  and 
sometimes  affect  several  members  of  a  family.  The  mother 
may  have  a  cervical  auricle,  and  one  of  her  children  a 
branchial  fistula,  whilst  another  child  may  have  an  auricle 
associated  with  a  fistula ;  they  are  often  symmetrical  (Fig.  247). 


478 


DERMOIDS 


A  cervical  auricle  consists  of  an  axis  of  yellow  elastic  carti- 
lage, which  sometimes  extends  deeply  into  the  tissues  of 
the  neck;  muscle-fibres  from  the  platysma  are  attached  to 
the  cartilage,  and  the  whole  is  surmounted  with  skin  con- 
taining hairs  and  sebaceous  glands.  A  small  arterial  twig 
runs  into  the  auricle  and  ramifies  in  the  fibrous  tissue  and 
fat  in  which  the  cartilage  is  embedded. 

Thus,  structurally,  cervical  auricles  are  identical  with  the 


1^ 


V 


■A" 


^% 


Fig.  248. — Head  of  a  goat  with  cervical  auricles. 

normal  auricle  or  pinna,  and  they  agree  with  the  pinna  mor- 
phologically, inasmuch  as  they  are  developed  like  it  from 
that  portion  of  a  branchial  bar  which  is  directly  in  relation 
with  the  corresponding  cleft. 

In  sharks  the  gill-shts  open  separately  on  the  surface  of 
the  body ;  from  the  branchial  bar  anterior  to  each  slit  a 
fold  of  skin  is  formed,  which  closes  upon  the  sht  like  a  lid 
and  is  named  from  this  resemblance  the  operculum.  In 
mammalian  embryos  a  slight  prominence  or  tubercle  is  for  a 
time  visible  anteriorly  to  each  of  these  clefts.     In  most  cases 


GERVIGAL   AURICLES 


479 


the  tubercles  disappear  from  the  posterior  bars,  but  those  in 
relation  with  the  anterior  cleft  enlarge  and  are  joined  by 
accessary  tubercles  to  form  the  pinna.  Thus  embryology 
has  taught  me  to  regard  the  pinna  as  consisting  mainly  of 
an  operculum  which  has  become  modified  for  acoustic  pur- 
poses, for  we  may  regard  the  tubercles  formed  in  relation 
with  the  branchial  clefts  of  man  as  representative  of  the 
opercula  of  certain  Ichthyopsida.  As  the  pinna  is  mainly 
derived  from  opercular  tubercles,  and  cervical  tubercles,  in 
all  probability,  represent  persistent  opercular  tubercles,  it  is 
reasonable  to  term  them  cervical  auricles. 


Fig.  249. — Head  of  a  homed  sheep  with  cervical  auricles. 

The  homology  of  at  least  a  part  of  the  pinna  and  cervical 
auricles  with  the  opercula  of  fish  has  been  made  clearer  by 
Schwalbe's  discovery  of  auricular  tubercles  in  the  embryo 
of  the  turtle  (Emys  lutaria  taurica) ;  in  the  adult  condition 
chelonians  have  no  vestige  of  an  auricle. 

Cervical  auricles  occur  in  mammals  other  than  man. 
Heusinger,  in  1876,  mentioned  the  frequency  with  which 
pendulous  tags  of  skin  occur  in  the  necks  of  pigs,  goats 
(Fig.  248),  and  sheep  (Fig.  249) ;  yet  very  little  has  been 
done  to   extend  his   observations. 

The  anatomy  of  these  auricles  (which  are  especially 
common  in  Egyptian  and  Italian  goats')  is  similar  to  that 


480  DERMOIDS 

of  cervical  auricles  in  man :  there  is  an  axis  of  yellow  elastic 
cartUage  embedded  in  fibrous  tissue  and  fat,  the  whole  being 
covered  with  hairy  skin. 

In  Great  Britain  cervical  auricles  are  rare  in  pigs,  but  Pro- 
fessor Anderson  Stuart  has  drawn  attention  to  the  existence 
in  Australia  of  a  breed  of  pigs  known  as  the  Bell-pig  on 
account  of  the  presence  of  pendulous  folds  of  skin  in  the  neck 
(Fig.  250).  It  may  here  be  mentioned  that  in  Germany  these 
auricles  in  sheep  and  pigs  are  known  as  Glockchen  or  Berlocken. 


^N\ 


Fig.  250. — Head  of  a  pig  with  cervical  amides  (the  Bell-pig  of  Australia). 

Before  concluding  the  subject  of  cervical  auricles,  reference 
must  be  made  to  the  presence  of  these  appendages  on  the 
necks  of  satyrs.  Mr.  Shattock  drew  my  attention  to  the  fact 
that  in  the  statues  of  many  satyrs  we  find  in  the  neck,  in  the 
situation  where  cervical  auricles  are  usuall}^  found,  promin- 
ences which  in  their  variety  of  form  resemble  the  cervical 
auricles  of  goats  and  men.  In  the  eegipans  (goat-footed 
satyrs)  the  auricles  in  the  neck  are  pointed  like  their  ears 
and  are  sessile,  but  in  the  fauns  they  are  usually  pendulous 
(Fig.  251).  In  the  statues  of  many  satyrs,  both  fauns  and 
segipans,  no  auricles  are  represented,  and  they  are  less  con- 


AUBIGULAR   FISTULJE  481 

stant  in  modern  than  in  ancient  statues  of  fauns,  and  in 
some  they  are  unilateral.  The  hircine  element  is  particu- 
larly evident  in  the  segipans,  even  in  their  tails  (Fig.  346). 

AURICULAR  FISTULA  AND  DERMOIDS 
We  may  assume  that  the  auricle  or  pinna  consists  mainly 
of  an  enormously  developed   operculum  which   ha,s  become 


Fig.  251.— faun  and  goat  with  cervical  auricles.     {From  the  Ccqntol.) 

utilized  for  acoustic  purposes.  It  has  already  been  pointed 
out  that  in  the  embryo  each  branchial  cleft  is  surmounted  by 
a  swelling  or  tubercle  corresponding  to  the  operculum  of  the 
shark.  In  mammals,  and,  as  Schwalbe  has  shown,  in  reptiles, 
the  first  cleft,  which  ultimately  becomes  modified  into  the 
tympano-Eustachian  passage,  is  surrounded  by  additional 
tubercles,  some  of  which  belong  to  the  mandibular  and  others 
to  the  hyoid  bar  (Fig.  252).  It  is  by  the  subsequent  growth 
2  F 


482 


DERMOIDS 


and  coalescence  of  these  tubercles  that  the  auricle  is  formed. 
These  tubercles  have  received  from  His  the  following  names  : 
I.,  tuberculum  tragicum ;  ii.,  tuberculum  anterius ;  iii.,  tuber- 
culum  intermedium;  iv.,  tuberculum  anthelicis;  v.,  tuberculum 
antitragicum  ;  and  vi.,  lobulus. 

The  subsequent  fate  of  these  tubercles  may  be  briefly 
given.  The  tuberculum  tragicum  unites  across  the  cleft  with 
the  tuberculum  antitragicum,  the  space  formerly  separating 
them  being  simply  indicated  by  the  incisura  intertragica. 
The  tuberculum  intermedium  is  the  source  of  the  helix, 
whilst  the  tuberculum  anthelicis  furnishes  the  anthelix :  the 
nodule  vi.,  cut  off  by  the  fusion  of  tragus  and  anti tragus, 
becomes  the  lobule. 

Imperfections   in   the   development   and   union   of  these 


Fig.  252. — Two  di-awings  representing  the  development  of  the  auricle  {sec  text  ahove). 
[Modified  from  Sis.) 

tubercles  will  serve  to  explain  several  congenital  defects  to 
which  the  auricle  is  liable.  Of  these,  three  are  of  especial 
interest:  (1)  auricular  fistulee;  (2)  auricular  dermoids;  (3) 
accessary  tragus. 

1.  Auricular  fistulse. — Heusinger  seems  to  have  been  the 
first  to  describe  a  congenital  fistula  in  the  helix.  For  the  first 
complete  account  of  these  fistulse  in  England  we  are  indebted 
to  Sir  James  Paget.  The  fistula  usually  appears  as  a  small 
opening. leading  into  a  canal  ending  blindly  in  the  substance 
of  the  helix.  The  auricle  may  be  of  good  shape,  but  often  it 
is  deformed  (Fig.  253).  Usually  a  small  quantity  of  greasy 
material  exudes  from  the  orifice  of  the  sinus,  ivhich  varies 
from  2  to  6  mm.  in   depth.     These  fistulse  sometimes  exist 


AURICULAR  FISTULA 


483 


in  individuals  who  also  have  branchial  fistuke ;  or  one  mem- 
ber of  a  family  will  have  a  congenital  fistula  in  the  auricle, 
and  another  a  congenital  fistula  in  the  neck :  they  are 
hereditary. 

It  is  far  rarer  to  find  congenital  fistulse  in  the  lobule. 
Very  few  examples  have  been  observed.  A  little  girl  known 
to  me  was  born  with  a  perforation  in  the  lobule  of  the  left 
auricle  exactly  in  the  spot  for  wearing  an  earring,  and  to 
this  day  she  wears  a  ring  in  this  lobule  and  refuses  to 
have  the  other  pierced. 


Fig.  2.53.— Congenital  fistula  in  the  helix.     {After  Paget.) 

The  facts  now  at  our  disposal  enable  us  to  understand  how 
such  fistulse  arise,  for  it  seems  reasonable  to  conclude  that  if 
the  various  lobules  which  conspire  to  form  an  auricle  unite 
imperfectly,  the  intervening  spaces  will  persist  as  sinuses  or 
fistuke. 

2.  Auricular  dermoids.— From  what  has  just  been  stated' 
regarding  the  probable  mode  of  origin  of  auricular  fistulse,  it 
will  be  obvious  that  if  unobliterated  skin-lined  spaces  are  left 
between  the  tubercles  uniting  to  form  the  auricle,  and  the 
skin  lining  such  spaces  possesses  glands  (sequestered  tracts  of 


484 


DERMOIDS 


skin  are  unusually  rich  in  sebaceous  glands),  we  have  in  such 
spaces  potential  dermoids. 

The  auricle  is  not  an  uncommon  situation  for  cysts  often 
described  as  sebaceous ;  they  are  usually  small,  but  sometimes 
attain  the  dimensions  of  a  cherry,  or  even  larger.  When 
these  supposed  sebaceous  cysts  are  examined  microscopically 
they  sometimes  turn  out  to  be  dermoids.  It  is  a  curious  fact 
that  unless  small  dermoids  in  unusual  situations  are  very 
carefully  examined,  they  run  a  great  chance  of  being  put 
aside  as  sebaceous  cysts. 

Auricular  dermoids  of  fair  size  sometimes  occuj)y  the 
groove  between  the  pinna  and  the  mastoid  process  ;  if  allowed 
to  grow  they  will  form  a  deep  hollow  in  the  imderlying  bone. 


Fig.  254. — Auricle  with  a 
duplicated  tragus. 


Fig.  255. — Aui-icle  of  a  fcetus  with 
an  unusually  large  Woolner's 
tip  f\rmished  with  a  tuft  of 
lanugo. 


3.  Accessary  tragus. — One  of  the  commonest  malform- 
ations of  the  pinna  is  duplication  of  the  tragus.  The 
accessary  tragus  is  extremely  variable  in  shape ;  often  it 
assumes  the  form  of  a  low  conical  projection  in  front  of  or 
above  the  tragus  (Fig.  254) ;  sometimes  it  is  pedunculated 
and  hangs  as  a  small  cutaneous  tag  slightly  in  front  of  the 
tragus,  beset  with  pale,  delicate  hair.  It  is  curious  that  an 
accessary  tragus,  a  Woolner's  tip  (Fig.  255),  and  a  mandibular 
tubercle  (Fig.  228)  are  usually  covered  with  long  lanugo. 

Occasionally  an  accessary  tragus  is  associated  with  a 
circular  cicatris-like  depression  in  the  cheek  immediately 
in  front  of  the  pinna.  It  is  a  fact  of  some  interest  that 
malformations  of  the  tragus  and  an  accessary  tragus  are 
often  associated  with  defects  in  the  mandibular  fissure,  such 
as  macrostoma,  mandibular  fistula,  and  tubercle. 


AURICULAR   TUBERCLE  485 

Woolner's  tip. — This  name  lias  been  given  to  a  small 
tubercle  often  present  on  the  margin  of  the  helix  (Fig.  255). 
It  was  noticed  by  Woolner,  the  celebrated  sculptor,  whilst  he 
was  at  work  on  his  statuette  of  Puck,  to  whom  he  gave 
pointed  ears.  The  urchin  is  "  perched  upon  a  toadstool  and 
with  liis  toe  rousinoc  a  froof."  Woolner  drew  Darwin's  atten- 
tion  to  this  tubercle  whilst  modelling  a  bust  of  the  famous 
naturalist.  After  a  careful  consideration  of  the  facts,  Darwin 
thought  it  probable  "  that  the  points  are  vestiges  of  the  tips 
of  formerly  erected  and  pointed  ears."  Woolner  made  his 
observation  at  the  age  of  22.  I  possess  a  fine  example  of  this 
famous  statuette. 

Heusinger,     "  Hals-Kiemen   Fisteln   von  noch  nicht   beobachteter   Form." — 

Arch./. path.  Anat.  (Virchow),  1864,  xxix.  358. 
Heuter,  C,  "  Grundriss  der  Chirurgie,"  1882,  ii.  328. 
His,    W.,  "Anatomie   menschlicher   Embryonen,"  1885,    Heft  iii.    (Die   For- 

mentwickelung  des  ausseren  Ohres),  p.  211. 
von  Kostanecki,  K.,  "  Beitiage  zur  Kenntniss  der  Mi.ssbildungen  in  der  Kopf 

nnd  Halsgegend." — Arch.  f. path.  Anat.  (Virchow),  1891,  cxxiii.  401. 
Paget,  Sir  J.,  "  Cases  of  Branchial  Fistulas  in  the  External  Ears." — Med.-Chir. 

Tram.,  1878,  Ixi.  41. 

Rowley,  "  Tumour  found  in  a  Frog  posterior  to  the  Angle  of  the  Jaw." — Trans. 

Leicester  Lit.  and  Fhilosoph.  Soc,  April,  189G. 
Schwalbe,  "  Ueber  Auricularhocker  bei  Eeptilien  ;  ein  Beitrag  zur  Phylogenie 

des  ausseren  Ohres." — Anat.  Anzeiger,  1891,  vi.  43. 
Watson,  Morrison,  "  Notes  of  a  Remarkable  Case  of  Pharyngeal  Diverticulum." 

— Journ.  Anat.  and  Phys.,  1874-5,  ix.  134. 


CHAPTER   XLVIII 

TUMOURS    OF   THE    FEMALE    GENITAL    GLAND 

(OVARY) 

The  ovary  is  a  complex  organ  histologically  and  morphologi- 
cally :  it  is  with  extraordinary  frequency  the  source  of 
tumours,  some  of  them  being  so  complex  in  character  as 
to  set  at  naught  the  ordinary  rules  of  oncological  classification. 
The  frequency  and  clinical  importance  of  ovarian  tumours 
justify  their  consideration  as  a  subdivision  in  a  general 
description  of  tumours. 

The  ovary  consists  morphologically  of  three  parts  :  (1)  the 
oophoron  ;  (2)  the  parooj)horon  ;  (3)  the  parovarium. 


Fig.  256.  —Diagram  representing  the  morpliologic  regions  of  the  ovary. 

A,  Oiiphoron  ;   b,  paroophoron ;   c,  parovarium  (epoophoron)  ;    K,  Kobelt's  tubes  ; 

G,  Gartner's  duct. 

1.  The  oophoron. — This  forms  the  free  surface  of  the 
ovary,  and  may  be  described  as  the  egg-bearing  segment,  for 
it  contains  the  ovarian  follicles. 

2.  The  paroophoron. — This  part  forms  the  hilum  of  the 
ovary :  it  consists  of  fibrous  tissue  and  blood-vessels ;  it  never 
contains  ovarian  follicles.     In  young  ovaries  glandular  tissue 

4SG 


TUMOURS   OF   THE   OVARY 


487 


may  be   detected,  remnants   of   tlie   mesonephros   (Wolffian 
body)  from  which  it  is  mainly  derived. 

3.  The  parovarium  (epoophoron). — A  structure  consist- 
ing of  a  series  of  tubules  situated  between  the  layers  of  the 
mesosalpinx.  These  tubules  at  their  ovarian  extremities  ter- 
minate in  the  paroophoron ;  at  the  opposite  end  they  open 
into  the  duct  of  Gartner;  this  duct  occasionally  may  be  traced 
downwards  to  the  vagina.  The  parovarium  and  the  duct  of 
Gartner  are  the   persistent  excretory  ducts   of  the  mesone- 


Fig.  257. — Cyst  of  the  ouf)horon.     {Xat.  size.) 
A,  Incipient  cyst ;  b,  paroophoron ;  F,  Fallopian  tube  ;  p,  parovarium. 


phros ;  in  the  female  they  are  vestigial,  but  in  the  male  they 
are  functional  as  the  excretory  ducts  of  the  testis. 

The  tumours  which  arise  in  the  ovary  Avill  be  described  in 
the  following  order,  viz. :  Dermoids  or  Embryomas ;  Lutein 
Cysts ;  Papillomatous  Cysts ;  Parovarian  Cysts  ;  Gartnerian 
Cysts  ;  Fibroids ;   Sarcomas  ;    Carcinomas. 

DERMOIDS  (EMBRYOMAS) 
The  ociphoron  is  the  source  of  three  varieties  of  tumour, 
known  as  cysts,  adenomas  (multilocular  cysts),  and  dermoids 
(or  embryomas),  which  in    their  type-forms   are  easily  dis- 
tinguished, but  they  approach  each  other  b}^  such  gradations 


488  TUMOURS   OF  THE  OVARY 

as  to  make  it  difficult  to  draw  a  dividing  line ;  moreover, 
conglomerate  tumours  are  occasionally  found  in  the  ovary, 
consisting  of  dermoids,  cysts,  and  adenomas. 

Simple  cysts. — These  may  be  unilocular  or  multilocular. 
A  small  oof)horonic  cyst  is  an  enlarged  ovarian  follicle,  and  its 
walls  are  furnished  with  a  well-developed  membrana  granu- 
losa. In  a  very  early  stage  it  is  easy  to  demonstrate  the 
relation  of  such  a  cyst  to  the  oophoron.  As  the  cyst  enlarges 
it  causes  rapid  absorption  of  the  paroophoron,  and  the  region 
in  which  it  arose  is  then  not  so  easily  demonstrable. 

It  is  only  by  patiently  waiting  for  opportunities  of  securing 
cysts  in  very  early  stages  that  it  is  possible  to  elucidate  their 
mode  of  origin.  Much  of  the  confusion  which  obscures  the 
pathology  of  this  question  is  due  to  the  fact  that  most  in- 
vestigators have  devoted  their  attention  mainly  to  large 
cysts. 

In  cysts  containmg  three  or  four  litres  of  fluid  the  walls 
will  be  found  to  consist  of  fibrous  tissue,  and  epithelium  is 
rarely  detected.  It  is  impossible  to  state  definitely  the  size 
of  a  cyst  in  which  the  epithelium  disappears.  The  absence 
of  epithelium  is  due  to  atrophic  changes,  the  consequence  of 
the  contmual  pressure  exerted  by  the  accumulating  fluid. 
Precisely  similar  changes  mscy  be  studied  in  the  mucous 
membrane  of  greatly  distended  gall-bladders.  In  large  multi- 
locular cysts,  although  the  big  loculi  may  be  destitute  of 
epithelium,  the  smaller  cavities  will  retain  their  epithelium, 
which  may  be  columnar,  cubical,  or  stratified. 

An  extremely  simple  means  of  determining  an  oophoronic 
tumour  is  to  note  the  relation  of  the  Fallopian  tube  ;  it  lies 
curled  up  on  the  cyst,  and  when  the  parts  are  stretched  the 
tube  and  tumour  are  separated  by  the  mesosalpinx. 

Adenomas  (multilocular  glandular  cysts). — This  is  an 
important  variety  of  tumour.  It  has  a  dense  fibrous  capsule, 
and  its  surface'  is  usually  lobulated.  These  tumours  attain 
colossal  dimensions  and  consist  of  innumerable  loculi  and  cysts 
which  vary  in  size  from  a  cavity  no  bigger  than  a  pea  to  one 
holding  a  litre  or  more  of  fluid.  Critical  dissections  of  such 
cysts  enable  us  to  recognize  three  varieties  of  loculi.  In 
typical  specimens  a  honeycomb-hke  mass  will  be  found 
projecting  into   some  of  the   larger   cavities  and  occupying 


OVARIAN  ADENOMAS  489 

usually  one-tliird  of  its  circumference,  so  that  a  section  of 
the  cavity  resembles  a  signet-ring.  Such  are  called  primary, 
whilst  the  cavities  occupying  the  honeycomb  portion  are 
secondary  cysts,  and  are,  as  a  nratter  of  fact,  mucous 
retention -cysts.      The  third  set  of  loculi  are  of  small  size,  and 


Fig.  258. — Portion  of  a  large  ovarian  adenoma,  showing  the  varieties  of  loculi. 
c,  Primary  ;  d,  secondary. 


histologically  are   indistinguishable  from   distended  ovarian 
follicles  (Fig.  258). 

The  primary  cysts  in  their  early  stages  are  lined  with  rich 
columnar  epithelium,  and  often  contain  mucous  glands  (Fig. 
259).  The  fluid  contained  in  the  loculi  of  ovarian  adenomas 
is  identical  in  its  physical  and  chemical  characters  with  mucus. 
Occasionally  it  is  as  thick  and  tenacious  as  jelly.     The  lining 


490 


TUMOURS   OF  THE   OVARY 


of  the  cavities  is  in  many  specimens  indistinguishable  from 
mucous  membrane. 

In  some  specimens  of  ovarian  adenomas  the  secondary 
locuH  give  rise  to  projections  on  the  periphery  of  the  tumour  ; 
when  numerous  and  close  together,  these  projections  cause 
the  tumour  to  resemble  a  colossal  bunch  of  grapes.  It  is  no 
uncommon  thing  for  a  loculus  of  an  ovarian  adenoma  to  burst 
into  the  belly.     When  this  happens  the  mucus  which  escapes 


Fio;.  259. 


-Section  of  the  wall  of  a  loculus  from  an  ovarian  adenoma,  showing  the 
glandular  disi^osition  of  the  epithelium. 


is  tolerated,  but  not  absorbed,  by  the  peritoneum.  When  the 
rent  in  the  loculus  is  not  repaired  the  glands  in  its  walls 
continue  to  secrete,  and  the  mucus  accumulates  in  the  belly, 
simulating  hydroperitoneum.  On  one  occasion  I  removed 
from  a  woman's  belly  three  gallons  of  inspissated  mucus 
of  this  kind  which  had  been  secreted  by  an  ovarian  aden- 
oma no  bigger  than  a  coco-nut.  The  belly  was  so  tightly 
stuffed  with  this  jelly-like  material  that  it  had  produced  a 
hernial  protrusion  at  the  umbilicus  and  the  left  femoral  ring, 
the  sac  in  each  case  beinof  crammed  with  thick  mucus. 


OVARIAN  GYSTS 


491 


Ovarian  cysts  with  ciliated  epithelium. — As  a  rule  the 
epithelium  found  in  the  type-forms  of  ovarian  adenomas 
is  tall  and  columnar,  and  it-  may  be  ciliated  (Fig.  261).  In 
1905  I  removed  a  fist-sized  unilateral  ovarian  tumour  from 
a  woman  45  years  of  age,  and  its  semi-solid  condition 
raised  in  my  mind  a  suspicion  of  malignancy.  On  the 
instant  of  removal  small  pieces  of  the  tumour  were  placed  in 
preparation  fluid  and  at  once  forwarded  to  Dr.  Bashford.     He 


Fig.  260.— Ovarian  adenoma  presentinga  cutaneous  clump  (d)  with  a  tuft  of  hair  (/;). 
{Museum,  St.  Thomas's  Hospital.) 

reported  that  the  tumour  contained  ciliated  epithelium,  and 
that  it  was  innocent  in  character.  I  subsequently  examined 
the  tumour  after  it  had  been  carefully  hardened,  and  the 
manner  in  which  the  solid  parts  are  connected  with  the 
periphery  of  the  tumour  is  exceptional  (Fig.  261).  The  solid 
parts  are  made  up  of  spaces  lined  with  columnar  cells ;  in  many 
of  the  cystic  spaces  the  epithelium  presents  cilia.  The  view 
that  the  tumour  is  of  an  innocent  nature  seems  correct,  for 
a  year  later  the  patient  was  in  excellent  health. 

The  source   of  this   ciliated  epithelium   is   a  matter  for 
conjecture,   but    Walthard,  who  published  the   results   of  a 


492 


TUMOURS   OF  TEE   OVARY 


painstaking  investigation  into  the  histology  of  the  human 
ovary  at  various  ages,  mentions  the  occasional  existence  of 
small  cysts  in  this  organ  lined  with  C3'lindrical  cells  without 
any  tendency  to  form  warts,  and  in  some  the  epithelium  is 
columnar  and  ciliated.  He  also  describes  small  epithelial 
bodies  in  the  ovary  which  have  no  connexion  with  ovarian 
follicles,  and  which,  he  believes,  arise  from  the  cell-bundles 


Fig.  261. — Ovarian  adenoma  in  section.      The  gland-spaces  were  lined  with 
columnar  epithelium,  and  some  of  them  were  ciliated. 

that  dip  into  the  ovarian  stroma,  and  out  of  which  the  true 
ovarian  follicles  evolve. 

Dermoids  (embryomas). — A  very  large  proportion  of 
oophoronic  cysts  contain  skm  or  mucous  membrane,  or  both 
these  structures,  and  some  of  the  many  organs  peculiar  to 
them,  such  as  hair ;  sebaceous,  mucous,  and  sweat-  glands ; 
dermal  bone,  horn,  nail,  nipples  and  mammse ;  teeth  also 
occur  in  great  numbers :  such  are  called  dermoids.  They 
may  be  multilocular  or  unilocular,  and  attain  a  weight  of  20 
or  even  40  kilogrammes.     Sometimes   a  cvst   will   be   lined 


OVARIAN  DERMOIDS 


493 


throughout  with   typical  mucous    membrane    covered    with 
regular  columnar  epithelium,  and  will  contain  mucous  glands. 


Fig.  262.— Ovarian  embryoma.     The   lower  part  of  the  tumoui-  contained  teeth- 
germs  in  early  stages  of  development,     h,  Tuft  of  hair. 

It  is  impossible  to  determine  in  many  cases,  from  a 
mere  naked- eye  examination,  whether  an  ouphoronic  tumour 
should  be  regarded  as  an  adenoma  or  a  dermoid.     In  practice 


494  TUMOURS   OF   THE  OVABY 

the  presence  of  a  tuft  of  hair  or  a  tooth  is  a  useful  and.  ready- 
way  of  settling  the  question.  Failing  this,  a  careful  micro- 
scopical examination  is  necessary.  For  instance,  the  tumour 
represented  (nearly  natural  size)  in  Fig.  262  consists  of  two 
parts;  one  a  thin- walled  cyst  (filled  with  sebaceous  material 
when  fresh)  lined  with  piliferous  skin.  The  lower  and  larger 
portion  resembled,  on  superficial  examiDation,  an  adenoma, 
and  was  nearly  solid.  A  small  tuft  of  lanugo-like  hair  in- 
duced me  to  make  a  careful  histologic  examination  of  the 
adjacent  tissue.  The  sections  revealed  an  extraordinary 
diversity  of  tissues  and  organs,  such  as  sebaceous  and  sweat- 
glands,  hair-germs,  skin,  teeth-germs  with  typical  enamel- 
organs  and  dentine  papillae,  epithelial  pearls,  and  shapeless 
masses  of  epithelium. 

Cysts  occur  in  the  oophoron  at  all  periods  of  life,  even  in 
very  young  children,  and  I  have  collected  records  of  over 
one  hundred  cases  in  girls  under  15  years  of  age  in  which 
ovariotomy  was  a  necessity  from  the  size  of  the  tumour. 
In  one  remarkable  case  an  ovarian  tumour  from  a  girl  of 
15  years  weighed  44  kilos;  the  girl  weighed  27  kilos  (Keen). 

Small  cysts  in  the  oophoron  are  very  common  at  birth, 
and  are  often  bilateral;  but,  so  far  as  I  am  aware,  after 
a  careful  and  prolonged  investigation  of  the  matter,  no 
authentic  example  of  an  ovarian  dermoid  has  been  observed 
in  a  child  before  the  end  of  the  first  year  of  life. 

Adenomas  and  dermoids  are  very  apt  to  affect  both 
ovaries  simultaneously ;  very  rarely  two  independent  derm- 
oids may  arise  in  one  ovary ;  and  it  is  a  fact  that  both 
ovaries  may  be  so  distorted  and  destroyed  by  dermoids  that 
the  true  ovarian  tissue  is  unrecognizable  to  the  naked  eye, 
yet  such  organs  are  able  not  only  to  dominate  menstruation 
but  to  discharge  their  egg -bearing  functions  successfully  (see 
Cullingworth,  Thornton,  and  F.  Page).  Bilateral  ovarian 
dermoids  have  been  observed  in  a  woman  of  92 ;  she  was  the 
mother  of  six  children  (Pollock). 

Rate  of  growth  of  ovarian  adenomas  and  dermoids. — 
Concerning  the  rate  of  growth  of  these  tumours  very  little 
is  known.  Therefore  the  following  observations  may  be  of 
interest : — 

1.  Ovarian  adenoma.  —  In  May,  1901,  I   removed   from  a 


OVARIAN  DERMOIDS 


495 


woman  45  years  of  age  a  typical  left  ovarian  adenoma  ot 
the  size  of  a  football ;  it  was  full  of  the  usual  colloid  stuff. 
The  right  ovary  was  very  carefully  examined  and  found  to 
be  normal.  In  February,  1903,  I  removed  from  the  same 
patient  an  ovarian  adenoma  of  the  size  of  a  football,  which 
had  originated  in  the  right  ovary. 

Thus  a  complex  glandular  tumour  of  the  size  of  a  football 
may  grow  from  an  ovary  apparently  normal  in  twenty- 
one  months. 

2.  Ovarian  dermoid.  —  The  following   case  is  recorded  by 


Fig.  263. — Enormous  ovarian  cyst  in  a  girl  17  years  of  age ;  it  contained 
78  litres  of  fluid.     {After  Bcnjot.) 

Flaischlen  :  In  May,  1887,  Ruge  ovariotomized  a  woman, 
removing  a  cyst,  as  large  as  a  child's  head,  which  had  arisen 
in  the  left  ovary.  The  right  ovary  was  inspected  and  found 
to  be  natural. 

In  June,  1888,  a  tumour  the  size  of  a  fist  was  detected  on 
the  right  side  of  the  pelvis.  In  December,  1890,  laparotomy'- 
was  again  performed,  and  a  dermoid,  containing  hair  and 
teeth,  removed. 

In  this  case  the  evidence  is  decisive  that  a  dermoid  'may 
arise  in  the  ovary  and  attain  dangerous  proportions  in  an 
ad.ult  woman  tuithin  the  space  of  three  years. 

That  a  tumour  containing  hair  and  erupted  teeth  should  be 
produced  in  the  course  of  three  years  is  not  inconsistent  with 
the  rate  at  which  these  organs  are  formed  under  normal 
conditions.     For  instance,  the  period  between  the  fertilization 


498  TUMOURS   OF   THE   OVARY 

of  an  ovum  and  the  eruption  of  the  milk  incisors  in  man  is 
about  fifteen  months ;  in  exceptional  instances  children  are 
born  with  incisors  above  the  gum.  In  such  cases  the  process 
occupies  less  than  nine  months. 

The  cutaneous  organs  found  in  ovarian  dermoids  pre- 
sent such  extraordinary  variation  as  to  demand  separate 
consideration. 

Skin. — This,  in  some  specimens,  is  very  thick,  but  it  rarely 
possesses  papillae,  and  when  present  they  are  not  furnished 
with  touch-corpuscles.  Pigment  is  occasionally  present.  An 
epidermis  may  be  demonstrated  ;  sometimes  it  is  very  thick, 
and  the  superficial  layers  are  shed  into  the  cavity  of  the 
dermoid  in  broad  flakes.  The  usual  arrangement  of  the 
epithelium  resembles  that  which  is  found  on  the  buccal 
mucous  membrane  rather  than  on  skin  in  general,  and  there 
is  no  stratum  granulosum.  The  subcutaneous  tissue  of 
dermoids  is  often  particularly  rich  in  delicate  fat. 

In  a  few  instances  the  epidermis  has  been  found  trans- 
formed into  nail.  An  ill-formed  nail  has  been  detected,  at 
the  extremity  of  a  piece  of  bone  resembling  a  phalanx,  by 
several  observers. 

Hair. — This  varies  in  length,  colour,  and  amount.  A 
single  tuft  coiled  into  a  ball  and  mixed  with  sebaceous  matter 
is  not  infrequent,  and  may  attain  a  length  of  50  cm.  Munde 
has  described  and  figured  a  specimen  in  which  a  tuft  of  hair 
in  an  ovarian  dermoid  was  1-5  metres  long.  Frequently  only 
a  few  hairs  are  found  scattered  on  the  cyst-wall,  or  the  hair 
may  be  rolled  into  balls  and  lie  free  in  the  cyst.  Occasionally 
the  shed  hair  will  "  felt."  The  colour  is  equally  capricious, 
and,  as  a  rule,  differs  from  that  on  the  exterior  of  the 
individual.  The  hair  in  such  cysts  changes  in  colour  with 
age,  and  in  elderly  persons  becomes  quite  white  and  is 
eventually  shed,  so  that  these  cysts  become  actually  bald. 
In  an  ovarian  dermoid  from  a  mare  the  hair  resembled 
that  on  the  animal's  mane  or  tail  (Pollock).  In  a  similar 
tumour  from  a  ewe,  wool  existed. 

Sebaceous  glands.  —  The  extraordinary  abundance  and 
large  size  of  these  glands  are  a  conspicuous  feature  of  typical 
ovarian  dermoids.  They  are  occasionally  transformed  into 
cysts,  and,  exceptionally,  horns  sprout  from  them. 


OVARIAN  DERMOIDS 


497 


Sweat-glands. — These  are  not  nearly  so  common  as  the 
sebaceous  variety,  and  usually  occur  in  irregular  isolated 
clusters.  1  have  as  yet  failed  to  detect  the  characteristic 
twist  of  the  duct  so  constant  in  normal  sweat-glands. 

Pidtaceoiis  material. — The  cavities  of  ovarian  dermoids 
are  often  filled  with  a  semi-fluid  mixture  of  epithelium, 
sebum,  fat,  shed  hairs,  and  often  cholesterin.     In  small  cysts 


rig.  26i. — Ovarian  dermoid  containing  3,930  epithelial  balls. 

the  sebum  is  sometimes  so  pure  as  to  be  quite  white  in 
colour. 

The  fat  may  be  liquid  at  the  temperature  of  the  body, 
but  solidities  after  its  removal.  In  some  dermoids  it  occurs 
in  lumps  of  the  density  and  colour  of  cacao-butter.  This 
variation  probably  depends  on  the  proportion  of  stearin  in 
the  fat. 

Epithelial  halls. — In  some  rare  cases  the  shed  epidermis 
forms  rounded  pill-like  bodies  which  I  ventured  to  call 
2  G 


498 


TUMOURS   OF  THE   OVARY 


epithelial  balls.  As  a  rule,  three,  four,  or  even  twenty,  and 
perhaps  fifty,  may  be  present.  In  one  remarkable  specimen 
which  I  examined,  the  number  amounted  to  3,930.  Each 
contained  one  or  more  hairs  as  a  nucleus,  around  which  the 
epithelial  masses  cohered  to  form  balls  (Fig.  264).  Bonney 
has  reported  a  similar  case,  collected  the  literature,  and 
attempted  to  demonstrate  by  experiment  the  probable  mode 
by  which  these  balls  are  formed.  These  pill-like  bodies  have 
been  found  in  dermoids  of  the  scalp  and  neck. 

Ovarian  mamvue  and  teats. — It  is  quite  common  to  find 


Fig  265. — Ovariau  mamma  with  hair  and  teeth. 

in  the  interior  of  ovarian  dermoids  one  or  more  tags  of  skin 
resembling  a  nipple  or  teat  associated  with  hair  and  teeth  (Fig. 
265).  These  teats  may  be  small  and  inconspicuous,  but  usually 
they  are  obvious  to  the  most  casual  observer.  Often  they 
are  attached  to  round,  skin-covered  prominences  resembling 
mammse.  These  teat-like  processes  are  imperforate  and  beset 
with  large  sebaceous  glands.  In  some  specimens  the  mamma 
is  plump  and  well-formed,  but  consists  entirely  of  fat  covered 
with  skin.     The  nipple  may  be  surrounded  with  an  areola. 

Complete  forms  are  sometimes  found  with  glandular  acini 
ducts  and  a  perforated  nipple,  and  furnish  a  viscid  fluid  which 
exhibits  the  microscopic  characters  of  milk  and  contains 
colostrum  globules. 


OVABTAR  DERMOIDS 


499 


The  most  complete  ovarian  mamma  from  a  histological 
point  of  view  is  one  described  by  Yelits:  the  nipple  was 
surrounded  by  a  rosy  areola  with  clusters  of  Montgomery's 
tubercles,  and  small  tufts  of  blond  hair.  Its  structure  was 
characteristic  of  a  mamma  (Fig.  266). 

Thyroid  gland. — In  1893  I  removed  a  large  ovarian 
tumour  from  a  woman  50  years  of  age,  and  detected  in  it  a 
firm,  rounded,  encapsuled  body  as  big  as  a  walnut.  Its  cut 
surface  so  resembled  a  thyroid  gland  that  I  examined  it 
microscopically.  The  body  was  composed  of  closed  vesicles 
filled  with  colloid  material  and  lined  with  the  sub-columnar 


Fig.  266. — Histologic  characters  of  the  ovarian  mamma  described  by  Velits. 
a,  Pigmented  connective  tissue  ;  b,  plain  muscle  fibre ;  c,  d  and  c^  gland-acini 
and  ducts. 

epithelium  so  characteristic  of  the  normal  thyroid  gland. 
Similar  observations  have  been  recorded  since  by  Kroemer, 
Bell,  and  Cleland. 

Bone. — This  tissue  is  often  present  in  ovarian  dermoids  in 
shapeless  masses  resembling  the  alveoli  of  jaws,  or  as  irregular 
plates  of  extremely  dense  bone,  "  similar  to  the  facial  bones  of 
an  osseous  fish  "  (Doran).  Occasionally  the  fibrous  capsule  of 
a  dermoid  becomes  calcified. 

Nerve-tissue. — Many  observers  have  detected  the  presence 
of  nerve-tissue  in  ovarian  cysts.  Gray  (1858)  described  such 
a  cyst  which  contained  tissue  indistinguishable  from  "  cerebral 


500  TVMOURS   OF  THE   OVARY 

matter."  In  one  instance  tlie  brain  substance  was  enclosed 
in  a  firm  capsule  in  structure  like  dura  mater,  lined  with  a 
delicate  pia  mater  (Neumann).  The  museum  of  St.  Thomas's 
Hospital  contains  an  ovarian  cyst  in  which  nervous  matter 
is  present  in  the  form  of  a  tubular  hydromyelic  sac.  This  has 
been  investigated  by  Shattock.  The  interior  of  the  sac  is 
lined  with  columnar  epithelium,  and  the  halves  of  a  spinal 
cord  lie  on  each  side  of  it.  The  opposite  ovary  of  the  patient 
contained  a  hydromyelic  sac,  furnished  with  a  delicate  separ- 
able lining  representing  the  meninges  of  the  dilated  nervous 
system,  and  an  outer  membranous  wall.  The  nervous  tissue 
consists  of  a  reticulum  of  fine  fibrils  provided  with  cells  having 
oval  nuclei,  and  in  it  there  lie  many  branching  nerve-cells 
furnished   with   conspicuous  nuclei  and  nucleoli. 

Cleland  has  described  an  ovarian  dermoid  containing 
cerebral  substance  dilated  into  a  sac  resembling  a  hj^clro- 
cephalus.  "  At  one  spot  was  a  large  mass  of  melanin  granules 
surrounded  by  fibrous  tissue."  It  is  suggested  that  this 
may  represent  the  choroid  coat  of  an  eye.  This  is  a  justifi- 
able interpretation.  Bauingarten  detected  a  curious  eye-like 
organ  in  an  ovarian  dermoid.  It  presented  a  transparent 
portion  shaped  like  a  watch  glass,  and  of  the  size  of  a 
pfennig,  corresponding  to  the  cornea.  When  bisected,  it 
contained  a  cavity,  the  size  of  a  cherry-stone,  filled  with 
clear  fluid.  The  walls  of  the  cavity  were  lined  with  a  delicate 
layer  of  pigmented  epithelium  resembling  the  uvea  of  a 
normal  eye.  Nothing  resembling  a  retina  was  detected. 
Pigmented  tissue  of  the  same  kind,  associated  with  neuroglia 
and  neuro-epithelium,  has  been  described  in  detail  by  Frank. 
The  nervous  tissue  found  m  ovarian  embrj^omas  is  very 
remarkable  in  another  Avay :  these  tumours  occasionally 
display  malignant  characters  and  disseminate  in  the  abdomen 
{see  p.  506).  When  these  disseminated  nodules  are  examined, 
many  contain  embryonic  brain-substance  such  as  neuroglia 
and  ganglion  cells  (Backhaus). 

Backhaus,  "  Ueber    ein  metastasirendes  Teratoma  Ovarii." — Arch.  f.    Gyn., 

I'JOl,  Ixiii.  159. 
Baumgarten,  "  Ueber  eine  dermoid  Cyste   des  Ovarium  mit  angenahnlicben 

Bildangen." — Virchow's  Arch.,  Bd.  cvii.  515. 


OVARIAN  DERMOIDS  501 

Bell,  R.  Hamilton,  "  On  the  Appearance  of  Thyroid-like  Structures  in  Ovarian 

Cysts.  "—Trans.  Obsfet.  Soc,  1905,  slvii.  242. 
Bland-Sutton,  J.,  '■  An  unusual  example  of  Rupture  of  an  Ovarian  Adenoma." 

—Trans.  Obstet.  Soc.  Lond.,  1899-1900,  xli.  98. 
Bonney,   V.,    "A   Dermoid    Cjst    containing   a  large   number   of  Epithelial 

BnWs:'— Trans.  Obstet.  Soc,  1902-1903,  xliv.  351. 
Cleland,   J.   B.,    "  Two  interesting  Human  '  Dermoid  Cysts  '   (Embryomata)  : 

(1)  containing    Tliyroid   Gland;    (2)  Cerebral    'Substance.'" — Austral. 

Med.  Gaz.,  1910,  p.  235. 
CuUingwortli,  C.  J.,  "  Three  Cases  of  Suppurating  Dermoid  Cyst,  of  or  near  the 

Ovary,  treated  by  Abdominal  Section." — St.  Tlwmas's  Hasp.  Bepts.,  1887- 

1889,  xvii.  139. 
Frank,  R.  T.,  "  A  Case  of  Malignant  Teratoma  of  the  Ovary." — Amer.  Journ. 

of  Obstet.,  1907,  Iv.  348. 
Gray,  H.,  "  An  account  of  a  Dissection  of  an  Ovarian  Cyst  which  contained 

Brain." — Med.-CMr.  Trans.,  1853,  xxxvi.  434. 
Kroemer,  P.,  "  Ueber  die  Histogenese  der  Dermoidkystome  und  Teratome  des 

Eierstocks."— .4rc7<.  f.  Gyn.,  1899,  Ivii.  322. 
Munde,  P.  P.,  "  A  Switch  of  Hair  five  feet  long  from  a  Dermoid  Cyst." — Trans. 

Kem  YotJ:  Obstet.  Soc,  1891,  Amer.  Journ.  of  Obstet.,  xxiv.  854. 
Neumann,  E.,  '•  Doppelseitiges  multiloculares  Dermoidcystom  mit  Neubildung 

centraler    Nervensubstanz   (zwei    seltene    FJiUe    von    Ovarialcysten)." — 

Virchow's  Arch.f.jmtli.  Anat.,  1886,  civ.  492. 
Page,  P.,  "  Acute  Peritonitis  after  Confinement ;  abdominal  section  ;  Dermoid 

Disease  of  both  Ovaries  ;  removal ;  recovery." — Lancet,  1893,  ii.  250. 
Pollock,   C.    Stewart,   "Cyst   of  the   Ovary  of  a  Mare  (with  report  on  the 

specimen)." — Trans.  Obstet.  Soc.  Lond.,  1889-1890,  xxxi.  234,  253. 
Shattock,  S.  G.,  "Ovarian  Teratomata." — Lancet,  1908,  i.  479. 
Thornton,  J.  Knowsley,  "  A  Case  of  Removal  of  both  Ovaries  during  Preg- 
nancy."—Traws.  Obstet.  Soc  Lond.,  1886-1887,  xxviii.  41. 
von  Velits,  D.,  "  Eine  Mamma  in  einer  Ovarialgeschwulst." — Virchow's  Arch, 
f.  imth.  Anat.,  1887,  cvii.  505. 


CHAPTER  XLIX 

TUMOURS    OF   THE    OVARY  (Continoed) 

MATURE  OF  THE  OVARIAN  DERMOID  (EMBRYOMA) 

It  has  been  held  by  several  writers  during  the  past  fifteen 
years,  myself  among  them,  that  dermoids  of  the  ovary  differ 
in  so  man}?-  respects  from  those  found  in  connexion  with 
the  embryonic  fissures  (sequestration  dermoids)  that  they 
require  separate  consideration  from  the  taxonomic,  anatomic, 
and  genetic  points  of  view.  The  idea  that  they  arise  from 
included  pieces  of  epiblast  I  have  always  endeavoured  to  com- 
bat. Apart  from  other  considerations,  it  must  be  remembered 
that  sequestration  dermoids  are  congenital,  whereas  there  is 
no  authentic  observation  of  a  dermoid  existing  in  the  ovary 
at  birth :  they  occur  in  infancy  and  early  girlhood,  and  often 
of  large  size.  For  some  years  I  made  a  careful  study  of  the 
ovaries  of  still-born  foetuses,  and  instituted  unremitting  in- 
quiries amongst  men  who  have  specially  interested  themselves 
in  the  question,  yet  no  specimen  of  this  condition  is  available. 
This  at  once  establishes  a  distinction  between  the  sequestra- 
tion dermoid,  the  teratoma,  and  the  so-called  dermoid  of  the 
ovary.    The  diS'erence  may  be  expressed  in  this  way : — 

1.  A  teratoma  arises  in  embryonic  life. 

2.  Sequestration  dermoids  are  formed  during  foetal  life. 

3.  Ovarian   dermoids  or  embryomas   are  of  postnatal 

origin. 

In  its  simplest  form  an  ovarian  embryoma  is  indistin- 
guishable from  the  common  dermoid  of  the  facial  fissures.  It 
is  a  cyst  lined  with  epithelium  furnished  with  hair.  In  a 
more  complex  form,  in  addition  to  hair  it  possesses  teeth, 
bone,  and  secreting  glands.  In  its  highest  form  there  are 
organs  such  as  a  piece  of  intestine,  soft  bud-like  processes 

502 


EMBRY0MA8 


503 


composed  ot  brain-tissue,  a  well-formed   vulva,  a  condition 
of  things  resembling  an    acardiac  foetus  (see  p.  428). 

It  has  been  pointed  out  by  Wilms  that  an  ovarian  dermoid 
presents  two  parts,  namely,  a  cyst  and  an  embryonal  rudi- 
ment. The  cyst  is  composed  of  fibrous  tissue  arranged  in 
wavy  bundles :  its  inner  aspect  is  lined  with  loose  connective 
tissue,  and  at  one  part  it  presents  a  skin -covered  surface 
of  variable  extent  usually  beset  with  hair.  Associated  with 
the  skin-covered  surface  there  is  an  "  embryonal  rudiment," 


Fig.  267. — Ovarian  dermoid  or  embryoma  containing  a  pseudc  -mamma, 
(Museum,  Eoyal  College  of  Stirgeons.) 

usually  in  the  form  of  a  nipple-like  process  (pseudo-mamma) 
(Fig.  267).  The  size  of  this  rudiment  varies  greatly;  it 
may  be  so  inconspicuous  as  to  be  easily  overlooked,  or  so 
large  as  to  strike  the  eye  of  the  least  observant;  or  the 
embryonal  rudiment  may  approach  the  complexity  of  an 
acardiac  foetus. 

Experience  teaches  that  ovarian  dermoids  do  not  always 
conform  to  this  simple  plan  of  construction  :  specimens  some- 
times come  to  hand  containing  many  cysts,  and  each  cyst 
contains  a  "  rudiment "  (Fig.  268) ;  moreover,  it  is  not  un- 
common to  find  more  than  one  nipple  or  pseudo-mamma  in 
a  cyst.     The  tissue  underlying  the  skin-clad  surface  contains 


504 


TUMOURS   OF  THE   OVABY 


glandular    tissue,    which     occasionally    is    so    abundant    as 
to   obscure   the   small   cutaneous   element. 

OVARIAN    ADENOMAS 
Much  careful  attention  has  been  given  to  the  histology 


Fig.  268.— Ovarian  dermoid  (embryoma)  comiDOsed  of  three  cysts,  each  containing 

an  "embryonal  rudiment." 

r.t.,  Fallopian  tube  ;  Jimb.,  tubal  fimbrije  ;  t,  teeth. 

of  the  complex  ovarian  embryomas,  and  many  investigators 
have  come  to  the  conclusion  that  they  arise  from  the  im- 
perfect development  of  ova.  This  theory,  however,  does 
not  satisfactorily  explain  the  occurrence  of  an  embryoma 
with  teeth  in  the  Fallopian  tube  (Orthmann)  or  in  the 
testicle. 


EMBBY0MA8  505 

In  view  of  the  opinion  that  the  ovarian  embryoma  may  be  an 
attempt  to  form  a  foetus  without  impregnation,  it  is  worth 
notice  that  in  1799  BaiUie,  in  describing  an  ovarian  dermoid 
containing  pilose  skin,  suet,  and  teeth,  observes  that  this 
change  has  been  generally  considered  as  the  very  imperfect 
rudiments  of  a  foetus  which  has  been  formed  in  the  ovarium. 
As,  however,  the  change  takes  place  in  the  ovarium  before 
the  uterus  would  appear  capable  of  functions  which  would 
begin  at  the  age  of  puberty,  and  where  the  hymen  is  entire,  it 
is  highly  probable  that  it  is  independent  of  impregnation. 

Interesting  as  all  these  questions  are,  the  practical  surgeon 
has  to  face  the  important  clinical  fact  that  some  of  these 
ovarian  embryomas  display  malignancy  in  its  most  dangerous 
form,  namely,  the  power  of  dissemination.  This  will  now  be 
considered. 

The  malignancy  of  ovarian  embryomas. — If  we  restrict 
the  term  dermoid  to  those  ovarian  tumour^  which  contain 
typical  dermic  elements  such  as  skin,  hair,  teeth,  skin-glands, 
and  the  like,  it  may  be  truly  said  that  they  are  the  most  benign 
tumours  which  attack  women.     There  is,  however,  an  interest- 
ing phenomenon  connected  with  them  requiring  considera- 
tion, and  which  I  have  ventured  to  term  epithelial  infection. 
The  details  of  several  carefully  described  cases  are  available 
in  which  the  peritoneum  has  been  found  dotted  with  minute 
knots,   furnished  with  small  tufts   of  hair,  growing   among 
visceral  adhesions,  even  as  high  as  the  liver.     (Moore,  1866, 
Kolaczek,  Fraenkel,  Grawitz,  Lucy,  Lawrence,  and  Melchior.) 
In  each  of  these  patients  there  was  a  dermoid  in  the  ovary, 
and  in  the  clinical  reports  of  some  of  them  there  Avas  a  dis- 
tinct history  of  an  injury  to  the  abdomen,  which  makes  it 
obvious  that  this  condition  could  be  explained  by  the  epi- 
thelial contents  of  the  dermoid  escaping  into  the  belly  and 
becoming  engrafted  on  the  peritoneum.     In  Lucy's  remark- 
able case  the  abdomen  contained  eleven  pounds  of  pultaceous 
matter  which  had  leaked  from  an  ovarian  dermoid.     Before 
operation   the   abdomen  pitted   on  palpation.     The  patient, 
a  woman  aged  32,  noticed  this  herself.     She  recovered  from 
the  operation. 

If  we  widen  the  group  of  ovarian  dermoids  so  as  to  em- 
brace the  ovarian  adenoma,  which  I  maintain  is  pathologically 


506  TUMOURS   OF   TEE   OVABY 

correct,  tlien  we  must   include  a  rare  variety  of  peritoneal 
infection  unmistakably  malignant. 

The  most  typical  examples  of  ovarian  adenomas  may 
infect  the  peritoneum,  I  removed  from  a  woman  51  years 
of  age  an  adenoma  the  size  of  a  football.  Two  years  later 
she  again  came  under  my  care,  and  I  removed  an  ovarian 
adenoma  of  the  opposite  ovary  which  had  burst  and  filled  the 
belly  with  the  usual  gelatinous  or  colloid  stuff.  Six  years 
after  the  second  operation  she  came  into  my  hands  again 
with  an  enormously  distended  belly  :  at  the  operation  the 
abdomen  was  found  filled  with  colloid  jelly,  and  the  whole  of 
the  peritoneal  surface  covered  with  a  nmltitude  of  small 
bodies  which  on  microscopic  examination  exhibited  the  large 
columnar  cells  so  characteristic  of  the  ovarian  adenoma. 
The  patient  was  alive  and  well  three  years  afterwards. 

In  contrast  to  this  the  following  facts  are  gloomy.  I  have 
records  of  three  cases  in  which  a  tumour  to  the  naked  eye 
and  to  the  microscope  seemed  to  be  an  ordinary  benign 
adenoma,  but  it  had  burst  before  removal  and  filled  the 
belly  with  the  usual  viscous  matter.  Before  these  patients 
recovered  sufficient  strength  to  leave  their  beds,  signs  of  re- 
current growth  made  themselves  obvious,  and  some  twelve 
weeks  later  the  patients  died  with  secondary  deposits  on  the 
peritoneum.  Recently  cases  of  this  kind  have  been  reported 
under  the  name  of  malignant  embryomas ;  in  some  of  them 
the  peritoneal  nodules  contained  cartilage,  epithelial  pearls, 
and  ganglion-cells.  It  has  also  been  shown  that  in  some 
of  the  cases  the  secondary  nodules  assumed  the  form  of 
grafts,  and  were  in  most  instances  confined  to  the  peritoneum, 
but  undoubted  cases  are  known  in  which  the  malignancy 
assumed  the  form  of  visceral  metastasis. 

In  1871,  Jessop  of  Leeds  recorded  briefly  a  case  illustrat- 
ing metastasis  in  connexion  with  a  dermoid.  The  patient 
was  a  girl  aged  13  years,  and  the  tumour  consisted  of  one 
large  cyst  with  several  smaller  ones  attached,  and  of  a 
mass  of  white  cheesy  matter  mixed  with  numerous  thin, 
colourless,  curly  hairs.  At  the  autopsy  cancerous  deposits 
were  found  in  the  liver,  right  suprarenal  capsule,  and  mesen- 
teric glands. 

Malignant  embryomas  of  the  ovary  are  rare,  and  occur  in 


LUTEIN  GY8T8  507 

young  adults  and  in  early  childhood.  Dudgeon  reports  a 
fatal  example  in  a  girl  aged  3^-  years. 

(For  a  careful  report  of  a  case  and  a  summary  of  the 
literature,  see  Targett  and  Hicks.) 

The  bearing  of  the  evidence  at  present  available  indicates 
that  the  more  closely  the  elements  of  an  ovarian  tumour 
conform  to  the  adult  type  of  tissue  the  more  benign  will  be 
its  clinical  course.  The  more  widely  the  glandular  elements 
depart  from  the  normal  type  the  more  prone  will  these 
elements  be  to  infect  the  peritoneum,  as  the  result  of  accident, 
or  if  in  the  course  of  an  operation  they  be  spread  about  the 
peritoneal  cavity. 

My  pathological  inquiries  convinced  me  of  the  import- 
ance of  this  observation,  and  since  1890  I  have  ceased  to  tap 
ovarian  cysts  in  the  course  of  removal,  no  matter  what  their 
size,  but  have  removed  them  entire. 

LUTEIN  CYSTS 
Perhaps  the  most  familiar  naked-eye  feature  displayed  on 
the  cut  surface  of  a  mature  ovary  is  the  yellow  body  known 
as  the  corpus  luteum.  All  who  have  been  seriously  inter- 
ested in  the  pathology  of  ovarian  cysts  have  noticed  the 
frequency  with  which  the  corpora  lutea  are  converted  into 
cysts.  Rokitansky  drew  attention  to  this,  and  held  the 
opinion  that  they  might  enlarge  and  form  tumours  large 
enough  to  become  clinically  important.  Cysts  arising  in 
corpora  lutea  do  attain  a  size  sufficient  to  admit  of  de- 
tection in  the  course  of  a  careful  bimanual  examination. 
When  these  cysts  are  small  their  nature  is  easily  determined 
by  the  thick  layer  of  yellow  material  which  lines  them ;  but 
as  the  cyst  increases  in  size  the  lutein  tissue  is  spread  out 
and  becomes  less  obvious,  until  it  fades  away  and  leaves  a 
transparent  thin-walled  cyst  which  would  not  be  regarded 
as  a  lutein  cyst  unless  examined  with  the  assistance  of  a 
microscope.  It  has  been  shown  by  Lockyer  that  an  ovary 
may  contain  two  or  even  a  cluster  of  lutein  cysts,  and  the 
condition  may  be  bilateral ;  in  this  event  the  consequent  en- 
largement of  the  ovaries  is  such  that  on  physical  examination 
a  tumour  of  some  size  can  be  detected  on  each  side  of  the 
irterus. 


508  TUMOURS   OF   THE   OVARY 

The  importance  of  lutein  cysts  in  the  ovaries  in  association 
with  the  disease  of  the  chorion  known  as  hydatidiform 
disease,  and  especially  those  cases  which  have  been  followed 
by  chorion-epithelioma,  are  considered  in  Chap.  XL. 

Fraenkel,  A.,  "  Ueber  Dermoidcysfcen  der  Ovarien  und  gleichzeitige  Dermoide 

(mit  Haaren)  im  Peritoneum." — Wien.  med.  WocJt.,  1883,  zxxiii.  865. 
Grawitz,  P.,  "  Casuistische  Mittheilungen  aus  dem  Patliologischen  Institut  zu 

Greifswald.    ii.,  Dermoidahnliche  Cysten  im  Peritoneum  und  Diaphragma." 

— Virchow's  AreJi.f.path.  Anat.,  1885,  c.  262. 
Kolakczek,    "  Peritonaeale  Metastasen    eines   Eierstocksdermoids   und  eines 

Beckensarcoms." — Virchow's  Arch. /.path.  Anat.,  1879,  Ixxv.  399. 
Lucy,  R.  H.,  "  Double  Dermoid  Cyst  of  the  Ovaries  with  rupture  into  the  peri- 
toneal cavity." — Lancet,  1910,  i.  1756. 
Lawrence,  T.  W.   P.,  and  Randall,  M.,"  Proc.  Boy.  Soc.  of  Ilecl.,  Obstetrical 

Section,  1908,  i.  106. 
Melchior,  Berl.  Uin.  Woch.,  1908,  p.  34." 
Moore,  C.  H.,  "  Dermoid  Ovarian  and  many  Piliferous   Cysts ;    spontaneous 

opening  of  the  former  at  the  navel." — Trans.  Path.    Soc.   Loncl.,  1867, 

xviii.  190. 
Orthmann,  H.  G.,  "  Ueber  Embryoma  Tubae." — Mo)iatsschr.  f.  Geb.  und  Gyn., 

1901,  liii.   119. 
Targett,  J.  H.,  and  Hicks,  H.  J.,  "  Two  Cases  of  Malignant  Embryoma  of  the 

Oxaxj:'— Trans.  Obstet.  /%^.,  1905,  xlvii.  287. 
Wilms,  M.,    "Ueber  die   soliden   Teratome  des   Ovariums." — ZeigUr's  Beit., 

1896,  xix.  367. 


CHAPTER  L 

TUMOURS    OF    THE    OVARY    (Contm«ed) 

PAPILLOMATOUS,  PAROVAPtlAN,  AND  GARTNERIAN 

CYSTS 

That  portion  of  the  ovary  wliicli  is  termed  the  paroophoron 
and  receives  the  terminals  of  the  parovarian  tubules  is  usually 
represented  in  an  adult  ovary  by  a  plug  of  connective  tissue 
which  is  occasionally  referred  to  as  the  "  tissue  of  the  ovarian 
hilum  "  ;  it  has  been  the  subject  of  much  careful  histologic 
investigation.  This  tissue  is  regarded  by  some  writers  as 
the  source  of  the  well-known  papillomatous  cysts  of  the 
ovary,  and,  as  epithelial  elements  occur  as  residues  of  the 
mesonephros  in  this  "  hilum  tissue,"  the  theory  has  a  mor- 
phologic basis.  In  addition,  the  tissue  is  probably  the  source 
of  some  of  the  ovarian  fibroids  and  sarcomas. 

Papillomatous  cysts  of  the  ovary. — These  differ  from 
the  simple  form  of  ovarian  cyst  in  having  their  inner  walls 
beset  with  soft  dendritic  warts.  In  the  early  stages  these 
cj^sts  do  not  affect  the  shape  of  the  ovary  until  they  attain 
an  important  size.  The  warts  vary  greatly  in  number ;  some 
cysts  contain  few,  in  others  they  are  so  luxuriant  as  to  burst 
the  cyst-wall  and  then  protrude  as  a  cauliflower-like  mass. 
In  some  the  warts  will  erode  the  wall  at  several  points,  and 
grow  out  as  soft  epithelial  buds. 

Coblenz  was  the  first  clearly  to  distinguish  these  cysts 
from  those  arising  in  the  parovarium  and  associate  them  with 
definite  structures.  His  observations  have  been  confirmed 
by  Doran,  who  has  devoted  great  attention  to  this  question. 

The  distinguishing  feature  of  these  parociphoronic  cysts 
is  that  they  contain  warts ;  but  all  ijapillomatous  cysts  of 
the  ovary  are  not  parooplioronic  in  origin.  It  will  there- 
fore be  convenient  in  this  chapter  to  consider  the  subject  of 
warts  in  relation  to  the  ovary.     A  paroophoronic  cyst  niay 

509 


510 


TU3I0UES   OF   THE   QVABY 


contain  one  large  tuft  surrounded  by  a  few  scattered  nodules, 
Avliereas  in  another  example  the  cavity  of  the  cyst  may  be  so 
stuffed  with  them  that  it  bursts.  The  museum  of  the  Royal 
College  of  Surgeons,  London,  contains  an  admirable  specimen 
illustrating  this.  It  is  thus  described  in  the  catalogue : — 
"  An  uterus  with  its  appendages.  A  mass  of  finely  lobulated 
and  pedunculated  growths  springs  from  the  site  of  each 
ovary,  the  substance  of  which,  with  follicles,  was  discovered 
on  close  search  at  the  roots  of  the  growths.     These  growths 


Fig.  269. — Ruptured  papillomatous  cyst  (right  half  of  the  specimen). 
{Jfuseuin,  Royal  College  of  Surgeons.) 

were  probably  enclosed  at  an  early  stage  in  a  cyst-wall" 
(Fig.  269.) 

There  can  be  little  doubt  that  the  opinion  expressed  in 
the  catalogue,  that  the  growths  were  probably  enclosed  at  an 
early  stage  in  a  cyst,  is  correct,  for  remnants  of  the  cyst-wall 
remain  on  the  specimen. 

A  distinction  must  be  drawn  between  rupture  of  the  cyst 
and  perforation  of  the  cyst-wall  by  the  papillomas.  In  the 
latter  condition  cauliflower-like  masses  of  warts  project  from 
the  surface  of  the  cyst  into  the  abdominal  cavity  ;  some- 
times at  one  spot,  sometimes  in  three  or  four  places.     When 


PAPILLOMATOUS   GYSTS  511 

such  cysts  burst,  the  fluid  they  contain  escapes  into  the 
belly ;  the  epithelium  derived  from  the  warts  infects  the 
peritoneum  and  leads  to  a  crop  of  warts. 

It  has  been  clearly  established  that  when  the  abdomen 
has  been  opened  for  the  removal  of  a  papillomatous  cyst  the 
peritoneum  has  been  found  studded  with  warts.  A  few  years 
later  the  abdomen  has  been  reopened  and  all  the  peritoneal 
warts  have  disappeared.  Thus  they  behave  like  warts  on  the 
skin.  This  fact  must  be  borne  in  mind,  or  the  operator  will 
hastily  assume  the  disease  to  be  malignant  when  he  finds 
general  peritoneal  infection.  The  disappearance  of  peritoneal 
warts  after  removal  of  the  primary  tumour  is  an  interesting 
fact,  and  may  be  probably  explained  in  this  way  :  The  life 
of  multiple  warts  is  often  very  transient,  and  this  is  probably 
the  case  with  peritoneal  papillomas ;  but  as  long  as  the  seed 
supply  continues  new  warts  spring  up,  last  for  a  time,  and 
die,  to  be  succeeded  in  their  turn  by  a  new  crop.  When  the 
source  of  epithelium  is  removed  by  operation,  the  warts  then 
existing  die,  and  the  crop  is  not  renewed.  Exceptionally 
these  papillomatous  cysts  rupture  into  the  connective  tissue 
of  the  mesometrium,  and  I  have  seen  warts  clustering 
around  the  urachus  as  high  as  the  umbilicus. 

The  dispersal  of  the  cells  from  these  emancipated  warts 
is  no  doubt  largely  effected  by  movements  of  the  intestines, 
in  addition  to  the  sudden  inundation  of  the  belly  when  the 
cyst  bursts ;  but  there  is  an  additional  complication  which 
not  only  favours  infection  but  is  in  itself  inimical  to  life, 
namely,  hydroperitoneum.  This  condition  differs  from  ascites 
in  the  circumstance  that  it  is  not  the  consequence  of  hepatic, 
cardiac,  or  renal  disease,  but  is  due  to  irritation  of  the  peri- 
toneum by  secondary  nodules  of  cancer,  warts,  tubal  disease, 
and  the  like.  Hydroperitoneum  is  a  constant  concomitant  of 
the  bursting  of  a  papillomatous  cyst.  When  the  cyst  is  re- 
moved the  exudation  ceases. 

One  of  the  most  remarkable  examples  of  hydroperito- 
neum associated  with  papillomatous  cysts  on  record  is  that 
described  by  Dr.  Pye-Smith.  In  this  case  a  woman  was 
tapped  for  hydroperitoneum,  between  August,  1884,  and  April, 
1894,  299  times.  On  readmission  for  the  300th  tapping  she 
died.     At  the  post-mortem  examination  a  papillomatous  cyst 


512 


TUMOURS   OF  THE   OVARY 


was  found  in  connexion  with  each  ovary.  These  cysts  could 
have  been  easily  removed.  The  peritoneum  was  beset  with 
warts. 

It  is  important  to  draw  a  distinction  between  epithelial 
infection,  which  is  such  a  marked  feature  of  papillomatous 
cysts  of  the  ovary,  and  cancerous  generalization  due  to  depor- 
tation of  malignant  cells  by  the  blood-  and  lymph- vessels.  It 
is  necessary  to  state  that  some  papillomatous  cysts  display 
malignancy   by  recurring  locally.     Pozzi  has  especially  em- 


Tube. 


Ovarian  ligament. 


Fig.  270. — Euptured  papillomatous  cyst. 

phasized  the  fact  that  a  great  number  of  patients  from  whom 
papillomatous  cysts  are  removed  make  complete  and  durable 
recoveries,  and  I  can  affirm  this  from  my  own  experience ; 
but  it  is  difficult  to  assert  that  the  recovery  is  permanent 
in  the  face  of  the  following  record : 

Pozzi  removed,  in  1878,  bilateral  papillomatous  cysts  of 
the  ovaries,  attended  with  very  abundant  hydroperitoneum^ 
from  a  woman  25  years  of  age;  recovery  was  complete 
for  twenty  years.  In  1898,  hydroperitoneum  reappeared, 
and  a  second  operation  was  performed,  but  the  recurrent 
tumour  could    not    be  removed  ;  the  peritoneal  cavity   Avas 


PAPILLOMATOUS   CYST'S 


5l^ 


drained,  and  the  patient  made  a  temporary  recovery.  She 
died  a  year  later.  Pozzi  also  writes  favourably  of  the  ad- 
vantage of  operating,  whenever  it  is  possible,  on  recurrent 
papillomatous  masses,  even  when  they  cannot  be  completely 
removed,  for  such  a  proceeding,  accompanied  by  temporary 
drainage,  is  distinctly  advantageous  to  the  patient. 

In  1899  I  removed  from  a  woman  40  years  of  age  bilateral 
papillomatous  cysts,  and  evacuated  a  large  quantity  of  free 
peritoneal  fluid.  In  1905  this  patient  again  came  under  my 
observation  with  a  large  tense  cyst  in  the  hypogastrium  as 
big  as  her  head.     I  enucleated  this  cyst ;  it  contained  turbid 


Fig.  271. — Warty  ovary  {Nat.  size.)  A,  Ovary;  p,  parovarium;  F,  Fallopian 
tube ;  B,  mesosalpinx.  Two  small  papillomatous  cysts  are  seen  in  relation 
with  the  tuho-ovarian  ligament. 

fluid  and  the  interior  was  beset  with  an  abundant  crop  of  soft, 
but  not  very  vascular,  papillomas.  She  was  in  good  health 
five  years  later  (1910). 

Papillomatous  cysts  of  the  ovary  are  most  frequent  be- 
tween the  twenty-fifth  and  fiftieth  years ;  they  are  the  rarest 
species  of  cysts  which  arise  in  this  organ.  In  most  instances 
they  admit  of  easy  removal,  but  occasionally  they  burrow 
deeply  between  the  layers  of  the  mesometrium.  In  some  of 
these  cases  it  simplifies  the  operation  to  remove  the  uterus 
with  the  cysts.  So  far,  in  all  the  cases  which  have  come 
under  my  observation  the  cysts  were  bilateral.  In  several 
patients  the  disease  was  much  more  advanced  in  one  ovary 
than  in  its  fellow. 
2  H 


514  TUMOURS   OF  THE   OVARY 

Warty  ovaries. — There  is  a  variety  of  papillomatous  cyst 
arising  in  the  mesosalpinx  independently  of  the  ovary  or 
Gartner's  duct.  These  cysts  are  usually  found  near  the  junc- 
tion of  the  tubo-ovarian  ligament  with  the  ovarj^,  and  burrow 
between  the  layers  of  the  mesosalpinx  (Fig.  271). 

When  fresh  they  are  transparent,  and  resemble  incipient 
parovarian  cysts,  but  they  are  unconnected  with  this  struc- 
ture. The  most  striking  feature  of  these  cysts  is  the  almost 
invariable  presence  of  a  tuft  of  warts.  It  is  difficult  to  be 
sure  of  the  presence  or  absence  of  the  warts  without  open- 
ing the  cyst.  The  warts  are  composed  of  very  dense  fibrous 
tissue.  In  this  respect  they  differ  in  a  striking  manner  from 
the  soft  vascular  processes  found  in  typical  papillomatous 
cysts.  Wart-containing  cysts  also  occur  on  the  free  surface  of 
the  ovary. 

PAEOVAEIAN  CYSTS 

The  parovarium  consists  of  a  series  of  narrow  tubules 
situated  between  the  layers  of  the  mesosalpinx  and  closely 
associated  with  the  paroophoron.  It  is  easily  seen,  when  the 
mesosalpinx  is  stretched  and  held  up  between  the  eye  and 
the  light,  as  a  series  of  tubules  radiating  from  the  ovary 
to  join  a  longitudinal  tubule  situated  at  a  right  angle  to 
them.  Although  the  tubules  converge  as  they  approach  the 
ovary,  nevertheless  they  remain  distinct.  Each  tubule  ends 
blindly,  and  is  usually  lined  with  epithelium.  In  form,  size, 
and  disposition  they  resemble  the  vasa  efferentia  of  the 
testis.  This  resemblance  was  observed  by  Rosenmiiller,  who 
discovered  this  structure  in  1801  whilst  prosecuting  ana- 
tomical researches  at  Erlangen.  The  parovarium  is  homo- 
logous with  the  vasa  efferentia  and  epididymis  of  the  testis, 
for  these  tubular  structures  in  the  male  and  female  are  the 
persistent  excretory  ducts  of  the  Wolffian  body  (mesonephros). 
In  the  female  they  are  vestigial,  whereas  in  the  male  they  are 
functional. 

When  present  in  its  typical  condition,  the  parovarium 
consists  of  three  parts  (Fig.  256) :  an  outer  series  of  tubules, 
free  at  one  extremity,  known  as  Kobelt's  tubes ;  an  inner  set 
termed  the  vertical  tubules  ;  and  a  larger  tube  running  at 
right  angles  to  the  vertical  tubules,  which  may  occasionally  be 


PABOVABIAN  GT8TS  515 

traced  downwards  to  the  vagina.  This  is  Gartner's  duct ;  it 
corresponds  to  the  vas  deferens  in  the  male.  The  parovarium 
contains  as  a  rule,  twelve  tubules ;  sometimes  as  many  as 
seventeen  may  be  counted,  and  in  other  specimens  as  few 
as  five. 

The  cysts  which  arise  in  the  parovarium  are  of  two  kinds ; 
the  more  frequent  are  small  pedunculated  cysts  connected 
with  Kobelt's  tubes.  They  rarely  exceed  a  pea  in  size, 
and  do  not  call  for  much  comment,  as  they  are  of  no  clinical 
importance.  They  need  to  be  mentioned,  however,  because 
they  are  often  confounded  with  the  hydatid  of  Morgagni. 
Occasionally  some  of  the  vertical  tubules  will  break  loose  and 
form  pedunculated  cysts.  Should  the  cyst  rupture,  it  may  be 
converted  into  a  tuft  of  fimbriae.  The  more  important  cysts 
are  sessile,  and  remain  between  the  layers  of  the  mesosalpinx. 
In  the  early  stages  it  is  easy  to  demonstrate  the  relation  of 
these  cysts  to  the  parovarium.  When  such  a  cyst  enlarges, 
it  burrows  between  the  layers  of  the  mesosalpinx  and  makes 
its  way  towards  the  Fallopian  tube,  which  becomes  stretched, 
because  the  abdominal  end  of  the  tube  is  fastened  firmly  to 
the  ovary  by  the  tubo-ovarian  ligament,  and  the  ovary  in  its 
turn  is  attached  to  the  side  of  the  uterus.  In  a  very  large 
cyst  the  Fallopian  tube  becomes  greatly  elongated,  and 
attains  a  length  of  40  cm.  In  spite  of  this  extreme  stretching, 
the  lumen  of  the  tube  is  rarely  obstructed,  and  its  abdominal 
ostium  can  usually  be  found,  the  fimbrige  being  indicated  by 
a  few  wattle-like  processes. 

Small  cysts  are,  as  a  rule,  transparent,  but  when  they 
exceed  the  size  of  a  coco- nut  this  transparency  is  lost,  and 
the  walls  become  thick  and  tough.  Small  parovarian  cysts 
are  lined  with  columnar  epithelium,  which  is  sometimes 
ciliated  ;  in  cysts  of  moderate  size  the  epithelium  becomes 
stratified,  and  in  large  cysts  it  atrophies  from  pressure.  Rarely 
they  contain  warts. 

The  fluid  in  a  parovarian  cyst  is  limpid  and  opalescent ; 
specific  gravity  1002  to  1007,  reaction  alkaline.  A  substance 
precipitated  by  alcohol,  is  present  in  large  quantity. 

In  big  cysts  the  fluid  is  often  turbid  and  may  contain 
cholesterin.  When  parovarian  cysts  burst  the  fluid  is  quickly 
absorbed,  and  excreted  by  the  kidneys. 


516 


TUMOURS   OF   THE   OVARY 


The  points  which  enable  a  large  parovarian  cyst  to  be  dis- 
tinguished from  an  oophoronic  cyst  are  these  :— 

1.  The  peritoneal  coat  is  easily  stripped  off. 

2.  The  ovary  is  usually  found  at  the  side  of  the  cyst. 

3.  The  cyst  is  generally  unilocular. 

4.  The  Fallopian  tube  is  stretched  over  the  cyst,  but  does 
not  communicate  with  it  (Fig.  272). 

5.  The  specific  gravity  of  the  fluid  does  not  exceed  1010, 
and  may  be  much  lower. 

6.  In   some    specimens   the   tissue  of  the  mesosalpinx  is 
greatly  thickened. 

It  was   formerly  believed   that   cysts  originating  in  the 


Fia 


272,— Cyst  of  the  parovarium,   showing  its    relation   to    ovary    and  tuhe 
A,  Oophoron  ;  b,  paroophoron  ;  r,  Fallopian  tube.     (|  nat.  size.) 


parovarium  rarely  exceeded  the  size  of  an  orange,  but  Bantock 
demonstrated  that  parovarian  cysts  may  attain  very  large 
proportions,  and  be  capable  of  containing  several  litres  of 
fluid.  The  largest  parovarian  cyst  which  has  yet  come 
under  my  care  contained  20  litres  of  turbid  fluid. 

The  age  at  which  parovarian  cysts  occur  is  of  some  in- 
terest. It  has  already  been  mentioned  that  cysts  of  the 
oophoron  are  encountered  at  any  period,  from  foetal  life  up 
to  extreme  old  age.  The  occurrence  of  a  parovarian  cyst  has 
not,  as  far  as  I  am  aware,  been  recorded  in  an  individual 
before  the  age  of  16;  many  undoubted  cases  have  been 
observed  at  17,  18,  and  19,  the  cysts  being  large  enough  to 
rise  above   the  pubes.     Before   16    the   parovarium   appears 


PABOVABIAN  CYSTS 


517 


to  be  quiescent,  but  on  tbe  advent  of  puberty  it  seems  to 
undergo  great  stimulation ;  a  very  large  proportion  of  cysts, 
generically  classed  as  ovarian,  removed  between  the  ages  of 
17  and  25,  arise  from  it. 


rig.  273.— Ovary  and  stump  of       111,  J  3ft  after  axial  rotation,  ending 

in  complete  detachment  of  a  parovarian  cyst. 

*  The  rounded  stump  of  the  tube  at  the  point  of  detachment. 

Parovarian  cysts  do  not  often  contract  adhesions,  even 
when  they  suppurate.  The  layers  of  the  mesometrium 
stretched    over  them  occasionally  contain   an  unusual   pro- 


518 


TUMOURS  OF  THE    OVARY 


portion  of  unstriped  muscle-fibre ;  they  rarely  suppurate. 
Like  other  forms  of  cysts  and  tumours  related  to  the  ovary, 
they  are  liable  to  axial  rotation  and  complete  detachment 
(Fig.  273). 

GARTNERIAN  CYSTS. 

A  large  experience  of  ovarian  and  parovarian  cysts  has 
served  to  convince  me  that  many  papillomatous  cysts  have 
an  origin  independent  of  the  paroophoron.     A  careful  study 


Gaitnei's  Duct 


Fig.  274. — Uterine  segment  of  a  cow's  vagina,  showing  two  large  cysts  developed 
in  the  terminal  segment  of  Gartner's  duct.     {Museum,  Royal  College  of  Surgeons.) 

of  the  relations  of  these  cysts  shows  that  many  of  them 
burrow  deeply  by  the  side  of  the  uterus,  and  even  extend 
along  the  wall  of  the  vagina. 

It  is  known  that  Gartner's  duct  occasionally  persists  in 
women,  and  after  leaving  the  parovarium  it  traverses  the 
layers  of  the  mesometrium  and  runs  down  the  side  of  the 
uterus  to  reach  the  vagina.  As  it  approaches  the  cervix,  it  is 
often  embedded  in  its  tissue. 

Evidence  is  slowly  accumulating  in  support  of  the  opinion 


GARTNERIAN  GY8TS  519 

that  some  papillomatous  cysts  of  the  mesometrmm,  especially 
those  which  burrow  deeply  by  the  side  of  the  uterus,  arise  in 
persistent  portions  of  Gartner's  duct,  near  its  termination. 
Cysts  arising  in  the  lowest  segment  of  this  duct  occasionally 
bulge  into  the  vagina. 

The  cystic  tendencies  of  Gartner's  duct  can  easily  be 
studied  in  cows  (Fig.  274).  In  these  animals  the  ducts  are 
sometimes  as  large  as  crow-quills.  Usually  they  become 
gradually  lost  on  the  sides  of  the  uterus,  but  occasionally 
they  may  be  traced  to  the  vagina. 

Bantock,  G.  G.,  "  On  the  Pathology  of  certain  so-called  Unilocular  Ovarian 

Gjsts."—l'rans.  Obstet.  Soc.  Land.,  1873-74,  xv.  105. 
Coblenz,  H.,  "  Zur  Genese  und  Entwickelung  von  Kystomen  im  Bereich  der 

inneren    weiblichen    Sexual organe." — Virchow's   Arch.  f.  path.   Anat., 

1881,  Ixxxiv.  26. 
Doran,  A.  H.  G.,  "  Proliferating  Cysts  in  the  Ovary  of  a  seven-months  Foetus." 

—Trans.  Path.  Soc,  1881,  xxxii.  147. 
Pye-Smith,  P.  H.,   "  Papillomatous  Tumours  of  both  Ovaries." — Trans.  Path. 

So3.,  1893,  xliv.  111. 


CHAPTER  LI 

TUMOURS    OF    THE    OVARY    (Continued) 
OVARIAN  FIBROIDS;  SARCOMAS  AND  CARCINOMAS 

Ovarian  fibroids. — Tumours  are  occasionally  met  witli  in 
the  ovary  which  in  their  naked-eye  and  microscopic  char- 
acters are  indistinguishable  from  the  very  hard  variety  of 
uterine  fibroid.  In  their  most  typic  form  they  are  easily  re- 
cognized, being  ovoid  in  shape,  regular  in  contour  and  smooth ; 
intensely  hard,  encapsuled  and,  as  a  rule,  free  from  adhesions. 
On  section  the  fibrous  tissue  displays  the  whorled  arrange- 
ment which  is  such  a  conspicuous  feature  of  the  hard  variety 
of  uterine  fibroids.  When  the  tumour  is  divided  in  such  a 
way  as  to  include  the  ovarian  ligament,  a  small  portion  of 
the  ovary  may  usually  be  detected  associated  with  the  liga- 
ment (Fig.  275).  Yirchow  described  and  figured  this  re- 
lationship of  the  ovarian  fibroid  to  the  ovary  in  1867. 

Ovarian  fibroids  sometimes  soften,  and  this  leads  to  the 
formation  of  spurious  cysts  in  their  substance.  Another 
feature  of  some  importance,  and  one  already  mentioned,  is 
their  intense  hardness ;  and  in  some  cases  this  is  so  obvious 
that  it  has  enabled  me  to  suspect  the  nature  of  the  tumour 
before  operation.  Ovarian  fibroids  are  prone  to  calcify ;  Hand- 
field-Jones  removed  a  calcified  tumour  of  this  kind  from 
a  woman  aged  19.  They  are  occasionall}^  complicated  with 
hydroperitoneum,  and,  except  in  this  circumstance,  they  rarely  . 
produce  any  very  obvious  impairment  of  the  general  health. 

Ovarian  fibroids  are  as  a  rule  unilateral,  but  I  have  in  one 
instance  found  both  ovaries  affected,  and  they  may  occasion- 
ally be  associated  with  uterine  fibroids ;  of  this  companion- 
ship I  have  seen  one  example.  It  is  also  usual  for  these 
tumours  to  be  encaj)suled  in  the  ovary,  no  matter  what  size 
they  attain ;  but  there  are  examples  which  grow  within  the 
ovary  and  project  from  its  surface  like  subserous  fibroids  of 

.520 


OVARIAN  FIBROIDS 


521 


tlie  uterus.  It  is  probable  that  some  tumours  known  as 
corpora  fibrosa  (Patenko),  supposed  to  arise  from  corpora  lutea; 
are  of  this  nature. 

However  much  ovarian  fibroids  may  resemble  uterine 
fibroids  in  possessing  definite  capsules,  and  in  their  gross  as 
well  as  minute  structure,  and  the  extraordinary  vortex-like 
arrangement  of  the  constituent  tissues^  they  differ  in  a  very 
marked  way  in  their  age-distribution.     Uterine  fibroids  only 


Ovary 


Fig.   275. — Ovariau  fibroid  in  longitudinal  section. 

30  years  of  age. 


{NfcL  size.)     From  a  patient 


arise  during  menstrual 


life,  which  in  its  widest  sense  gives 
them  an  age-limit  of  thirty  years  (15  to  45),  but  ovarian 
fibroids  arise  in  advanced  life.  In  fourteen  cases  under  my 
own  observation  the  youngest  patient  was  27  and  the 
oldest  73  ;  in  one  patient  the  tumour  had  undergone  axial 
rotation  and  twisted  its  pedicle.  One  tumour  complicated 
pregnancy  and  was  successfully  removed.  McCann  removed 
a  tumour  of  this  kind  from  a  woman  73  years  of  age  ;  she 
was  well  four  and  a  half  years  later. 


522  TUMOURS   OF   THE    OVAEY 

The  earliest  age  at  which  these  tumours  have  been  ob- 
served is  the  twentieth  year.  This  was  a  case  reported  by 
Doran,  in  which  the  patient  married  at  15,  but  had  borne 
no  children.  Previously  to  the  removal  of  the  tumour  by 
Knowsley  Thornton  (1884)  sexual  desire  appears  to  have  been 
absent.  After  recovery,  this  instinct  rapidly  developed ;  the 
patient  left  her  husband,  and  bore  a  child  to  another  man. 
Ultimately  she  returned  to  her  home  in  good  health. 

Baillie  (1799)  gives  a  good  figure  of  an  ovarian  fibroid, 
and  writes  "  that  it  resembles  exactly  in  its  texture  "  uterine 
fibroids,  and  draws  attention  to  its  rarity. 

Ovarian  fibroids  occasionally  complicate  pregnancy  and 
have  led  to  Csesarean  section. 

One  of  the  greatest  difiiculties  in  connexion  with  our 
knowledge  of  the  solid  tumours  of  the  ovary,  especially  the 
variety  termed  fibroma,  has  been  the  absence  of  information 
concerning  the  after-history  of  those  patients  who  have  been 
submitted  to  operation.  This  defect  has  been  removed  by 
the  publications  of  Doran,  Briggs  and  Fairbairn.  I  have 
followed  up  the  after-history  of  ten  patients'  under  my  care. 
Nine  were  alive  at  intervals  varying  from  one  to  six  years 
after  operation.  One  died  three  months  after  the  operation 
from  a  chronic  affection  of  the  lung  and  pleura. 

The  results  of  careful  inquiries  into  the  after-history  of 
patients  who  have  had  ovarian  fibroids  removed,  establish 
clearly  that  these  tumours  are  as  innocent  as  the  hard 
variety  of  uterine  fibroids.  The  immediate  result  of  the 
removal  of  such  tumours  is  excellent,  even  when  associated 
with  hydroperitoneum. 

Sarcoma  of  the  ovary. — The  ovary,  like  other  paired 
organs^  is  very  prone  to  become  the  seat  of  sarcoma  in  early 
life :  to  this  succeeds  a  period  of  comparative  immunity, 
followed  by  a  second  period  of  renewed  but  diminished 
liability. 

Ovarian  sarcomas  in  girls  differ  in  several  points  from 
those  found  in  women,  and  their  histologic  peculiarities  are 
such  that  I  proposed  the  term  oophoromas  for  them ; 
they  attack  both  ovaries  in  about  half  the  cases,  grow  very 
rapidly,  often  attain  formidable  proportions,  and  quickly 
destroy  life. 


8AB.G0MA   OF  THE   OVARY  523 

Their  removal  is  attended  with  an  excessively  high  rate 
of  mortality,  and,  in  the  patients  who  recover,  quick  recur- 
rence is  the  rule. 

In  structure  they  consist  of  round  or  spindle  cells,  in 
which  collections  of  cells  are  often  conspicuous,  resembling  the 
alveolar  disposition  of  cancer.  This  appearance  is  due  to  the 
entanglement  of  ovarian  follicles  in  the  sarcomatous  tissue. 

Sarcomas  are  rare  in  the  ovaries  between  the  sixteenth 
and  twentieth  years  ;  after  this  age  they  are  encountered 
occasionally,  and  as  a  rule  are  unilateral.  The  two  common 
periods  for  sarcoma  to  arise  in  the  adult  ovary  are  from 
the  twentieth  to  the  thirtieth  years,  and  after  the  meno- 
pause. The  hard  encapsuled  tumours  of  the  ovary  formerly 
classed  among  the  sarcomas  are  now  described  as  ovarian 
fibroids,  and  are  free  from  the  odium  of  malignancy. 

Many  ovarian  sarcomas  arise  quickly,  attain  very  large 
proportions  often  in  a  few  months,  and  are  accompanied  by 
hydroperitoneum  and  marked  leucocytosis.  Such  tumours 
are  very  soft  and  succulent,  and  occupied  by  spurious  cysts 
due  to  degenerative  changes.  Microscopically  they  consist  of 
round  or  oat-shaped  cells,  and,  as  a  rule,  the  more  these  cells 
predominate  the  more  ominous  is  the  outlook  for  the  patient. 
Often  the  cellular  elements  burst  the  limiting  tissues  of  the 
tumour,  and,  implicating  adjacent  organs — such  as  uterus, 
bowels,  bladder,  veins,  and  arteries — render  removal  during 
life  impossible.  Dissemination  also  occurs,  and  life  is  often 
destroyed  within  a  few  months  of  the  onset  of  symptoms. 

Some  of  these  rapidly-growing  tumours  of  the  ovary 
are  described  by  German  writers  as  endotheliomas. 

Ovarian  sarcomas  are  more  common  in  children  than  in 
adults,  and  have  been  observed  even  in  a  foetus  (Doran). 
I  collected  from  current  literature  one  hundred  cases  of 
ovariotomy  in  girls  under  15  years  of  age.  Of  this  series 
forty-one  were  simple  cysts  or  adenomas,  and  thirty-eight 
were  typical  dermoids  ;  the  remaining  twenty-one  being 
sarcomas.  This,  however,  is  far  short  of  the  real  propor- 
tion of  sarcomas,  because  there  are  many  records  in  which 
no  operation  was  undertaken,  the  descriptions  being  based 
on  post-mortem  examinations. 

Another    important    feature    was    the    heavy    mortality 


524  TUMOURS   OF   THE   OVABY 

among  the  patients  with  sarcomas  submitted  to  operation. 
Seven  out  of  the  twenty-one  patients  died,  and  of  the  four- 
teen who  recovered  I  was  able  to  ascertain  that  four  died 
from  recurrence  within  a  year  of  the  operation.  (The 
tables  are  furnished  in  my  work,  "  Surgical  Diseases  of  the 
Ovaries,"  second  edition,  1896.) 

The  youngest  child  on  record  who  has  been  operated 
on  for  sarcoma  of  the  ovary  Avas  one  of  33.  months.  Un- 
fortunately, death  occurred  a  few  hours  after  the  operation. 
(Hoffman.) 

Carcinoma  of  the  ovary. — The  observations  of  Schla- 
genhaufer,  Cuthbert  Lockyer,  Briggs  and  Walker,  and  my 
own,  show  that  many  large  tumours  of  the  ovaries,  unilateral 
and  bilateral,  which  exhibit  the  structure  of  cancer  and  were 
formerly  regarded  as  arising  primarily  in  the  ovary,  are  in 
reality  secondary  to  cancer  situated  in  some  other  organ. 
The  relationship  of  the  ovarian  masses  to  cancer  in  some 
other  organ  is  demonstrated  by  the  fact  that  the  minute 
structure  of  the  tumour  in  the  ovary  varies  according  to 
the  situation  of  the  primary  focus.  Thus,  when  the  infec- 
tion of  the  ovary  is  secondary  to  a  cancer  somewhere  in 
the  gastro-intestinal  tract,  the  ovarian  tumour  presents  the 
features  of  gastric  or  colic  cancer.  When  the  disease  is 
secondary  to  carcinoma  of  the  breast,  it  will  have  the 
characters  of  mammary  cancer.  The  common  situations  for 
cancer  liable  to  infect  the  ovary  are  the  gastro-intestinal 
tract,  the  gall-bladder,  the  breast,  the  uterus  and  Fallopian 
tube. 

In  my  early  observations  I  thought  it  was  only  the  solid 
tumours  of  the  ovaries  that  could  be  placed  in  this  category, 
but  a  longer  experience  has  taught  me  that  if  a  woman 
whose  peritoneum  is  invaded  by  cells  from  a  cancerous  lump 
in  the  breast,  stomach,  or  colon  has  an  ovarian  cyst  in  her 
pelvis  and  the  cancer-particles  become  implanted  on  it,  they 
give  rise  to  a  malignant  cystic  tumour  of  the  ovary.  This 
occurs  more  frequently  than  published  records  would  lead 
us  to  suspect.  Moreover,  in  some  of  the  cases  where  an 
ovarian  cyst  co-exists  with  primary  cancer  of  the  Fallopian 
tube,  the  cyst  may  become  cancerous  by  implantation,  as 
explained  in  Chap,  xxxix. 


GARGINOMA  OF  THE   OYAEY 


525 


It  is  astonishing  to  find  what  a  large  number  of  these 
cases  are  missed.  Owiriotomy,  unilateral  and  bilateral,  has 
been  often  performed  and  the  primary  cancer  in  the  stomach 
or  intestine  overlooked,  although  the  patient  has  exhibited 
the  signs  common  to  these  conditions,  such  as  pain,  vomit- 
ing, and  progressive  emaciation.  In  cases  of  bilateral 
tumours  of  the  ovaries  accompanied  by  vomiting  and 
ascites,  a   careful    examination    of   the    abdominal    viscera, 


Fig.  276. 


-Ovarian  tumour  in  section.     It  consists  of  nodules  of  carcinoma, 
primary  growth  arose  in  the  colon. 


The 


especially  the  stomach,  should  be  made.  Primary  foci  of 
malignant  disease  in  the  gastro-intestinal  tract  are  easily 
overlooked  unless  especially  sought,  either  because  they  often 
occupy  a  position  that  is  not  exposed  in  the  course  of 
an  operation,  or  on  account  of  their  small  size.  On  several 
occasions  I  should  have  missed  a  primary  cancerous  focus 
in  the  course  of  an  ovariotomy  unless  I  had  deliberately 
examined  the  gastro-intestinal  tract.  It  is  a  significant  fact 
that,  whenever  surgeons  have  made  inquiries  into  the  remote 
results  of  ovariotomy,  they  have  been  astonished  to  find  that 
many   of    the   patients   have    perished  from    recurrence    in 


526  TUMOURS   OF  THE   OVARY 

the  abdomen,  or  from  intestinal  obstruction.  The  fact  that 
many  of  these  large  tumom^s  of  the  ovaries  are  due  to 
implantation  of  cancerous  cells  from  a  primary  focus  in 
another  organ  offers  a  satisfactory  explanation  of  many 
such  unhappy  sequences. 

Handley  has  demonstrated,  in  a  most  convincing  manner, 
that  cancer  of  the  breast  spreads  by  permeating  the  deep 
fascia ;  by  an  insidious  process  the  cancer-cells  slowly  creep 
along  the  lymphatics  of  the  fascial  plexus  until  they  reach 
the  epigastrium  immediately  below  the  ensiform  cartilage : 
at  this  point  the  cancer-filled  lymphatics  of  the  fascial 
plexus  in  the  middle  line  are  separated  from  the  sub- 
peritoneal fat  only  by  a  simple  layer  of  fibrous  tissue. 
Through  this  weak  defence  the  cancer-cells  slowly  find 
their  way  into  the  general  peritoneal  cavity  and  engraft 
themselves  on  the  omentum  and  other  suitable  visceral 
plots,  whereon  they  thrive  and  grow  into  metastatic  nodules, 
or  lumps.  Many  of  these  infecting  cells  are  conveyed  into 
the  pelvis,  and  lodge  on  ovary.  Fallopian  tube,  uterus,  or 
pelvic  peritoneum.  The  fluid  normally  present  in  the  belly 
serves  as  an  admirable  vehicle  for  the  transport  of  such 
cells,  easily  enabling  them  to  reach  the  pelvic  recesses, 
where  they  remain  undisturbed  and  grow  into  deadly 
masses.  If  we  apply  Handley's  observations  on  the  ser- 
pigmous  spread  of  mammary  cancer  to  a  primary  cancer 
in  the  stomach,  gall-bladder,  or  colon,  we  may  read  its 
course  in  this  way :  Arising  in  the  mucous  membrane, 
it  slowly  permeates  it  and  implicates  the  submucous,  mus- 
cular, and  peritoneal  coats ;  the  cancer-cells  can  then  escape 
freely  into  the  great  serous  cavity  and  be  distributed  by 
the  fluid,  aided  by  the  movements  of  the  bowels,  and  gradu- 
ally reach  the  pelvis  and  other  abdominal  recesses.  In  the 
pelvis  the  most  obvious  organs  on  which  they  could  fall 
would  be  the  ovaries,  as  these  so  often  rest  on  its  floor. 
Under  such  conditions  the  ovaries  may  be  fairly  pictured  in 
the  mind  as  receiving  a  covering  of  falling  cancer-cells,  as 
evergreen  shrubs  are  clothed  by  snowflakes  in  winter. 

The  fact  that  other  parts  of  the  internal  genitalia  receive 
these  cells  is  a  matter  of  some  importance,  because  one  of 
the  most  striking  features  of  operations  for  the  removal  of 


GAEGINOMA   OF  THE  OVARY  527 

malignant  ovaries  is  the  rapidity  with  which  the  disease 
recurs.  Lockyer  made  a  valuable  observation  relating  to 
this  :  he  examined  microscopically  the  tumours  removed  for 
bilateral  carcinomatous  disease,  and  although  the  attached 
tube  and  mesosalpinx  belonging  to  each  tumour  appeared 
normal  to  eyes  and  fingers  when  examined  macroscopically, 
they  were  found  extensively  infected  with  cancer  through  the 
lymphatics.     Under  these  conditions  I  have  found  one  ovary 


rig.  277.  —  Cancerous  ovary,  secondary  to  cancer  of  the  colon,  in  section.    The 
Fallopian  tube  is  infected  by  the  cancer.     From  a  woman  aged  56  years. 

as  large  as  an  orange,  due  to  secondary  cancer,  and  its 
companion  smaller  than  normal,  yet  on  microscopic  examin- 
ation it  also  was  permeated  with  cancer. 

Treatment. — The  outcome  of  these  pathological  observa- 
tions will  determine  those  who  have  to  deal  with  bilateral 
malignant  tumours  of  the  ovaries  to  examine  carefully  the 
patient  for  evidence  of  primary  cancer  in  the  gastro-intestinal 
tract.  If  the  disease  is  in  such  a  position  that  it  can  be 
excised  with  good  prospect  of  success,  this  may  be  done. 
Then  it  will  be  necessary  to  remove  not  only  the   infected 


528  TUMOURS   OF  THE  OVARY 

ovaries  but  the  tubes,  adjacent  segments  of  the  mesometria, 
and  the  uterus.  In  many  instances  the  removal  of  these 
large  ovarian  masses  is  urgently  needed  in  order  to  make 
the  patient  comfortable.  Operations  of  this  kind  can  only 
be  carried  out  with  hopeful  prospects  when  there  is  no  other 
evidence  of  gross  infection  than  that  afforded  by  the  ovaries. 

Baillie,  M.,  "  Morbid  Anatomy  of  the  Human  Body,"  London,  1799,  PI.  vii. 
Bland-Sutton,  J.,  "A  Clinical  Lecture  on  Secondary  (Metastatic)  Carcinoma 

of  the  Ovaries."— Srit.  Med.  Journ.,  1906,  i.  1216. 
Bland-Sutton,  J.,  "Cancer  of  the  Ovary." — Brit.  Med.  Journ.,  1908,  1.  5. 
Briggs,  "Fibroma  of  the  Ovary." — Brit.  Med.  Journ.,  1897,  i.  1083. 
Doran,  A.,  "  Fibroma  of  the  OvnYj."~Tra7is.  Obstet.  Soc,  xxxviii.  187. 
Doran,  A.,  "  Large  Ovarian  Tumours  in  a  seven-months  Child." — Trans.  Path. 

Soc,  xl.  200. 
Fairbaim,  J.  S.,  "  Fibroid  Tumour  of  the  Ovary." — Trans.   Obstet.  Soc.,  1903, 

xliv.  177. 
Handfield-Jones,  M.,  "Calcified  Ovarian  Fibroma." — Trans.  Obstet.  Soc,  1906, 

xlviii.  332. 
Handley,  W.  S.,   "  Dissemination  of  Mammary  Cancer." — Brit.  Med.  Journ., 

1905,  i.  663. 
Lockyer,  Cuthbert,  "  Carcinoma  in  the  Muscular  Wall  of  the  Uterus  Secondary 

to  Cancer  of  both  Ovaries." — Trans.  Obstet.  Soc.  Lond.,  xlvi.  302. 
Schlagenhaufer,  Fr.,  "  Ueber  das  metastische  ovarial  Carcinom  nach  Krebs  des 

Magens,  Darmes  und  andere  Bauchorgane." — MonatscU.  f.  Geb.  und  Gyn., 

Berlin,  1902,  xv.  485. 
Virchow,  R.,  "  Die  Krankhaften  Geschwtilste,"  1867,  iii.  224. 


CHAPTER  LII 

TUMOURS    OF    THE    OVARY    (Conceded) 

AXIAL  KOTATION  OF  OVARIAN  TUMOUES :   EPITHELIAL 
INFECTION  AND  SUPPURATION  OF   OVARIAN  CYSTS. 

In  1865  Rokitansky  drew  attention  to  the  fact  that  ovarian 
and  uterine  tumours  sometimes  rotate  and  twist  their 
pedicles,  or  drag  upon  them  in  such  a  manner  as  to 
compress  the  vessels  traversing  the  pedicles,  the  proper 
nutrition  of  the  tumours  thus  being  interfered  with.  Occa- 
sionally the  torsion,  and  in  some  instances  also  the  tension 
on  the  pedicle,  lead  to  complete  detachment  of  the  tumour. 
He  also  drew  attention  to  the  fact  that  certain  abdominal 
viscera  are  apt  to  undergo  axial  rotation.  Of  recent  years 
much  attention  has  been  devoted  to  this  subject,  and 
accumulated  observations  have  served  to  show  that  almost 
every  variety  of  abdominal  tumour  and  all  the  viscera, 
except  the  liver,  are  liable  to  this  accident. 

That  a  tumour  hanging  freely  in  the  belly  should,  by 
mere  alteration  of  the  position  of  the  body,  or  by  motion  im- 
parted to  it  by  a  tumult  of  the  bowels,  spin  round  and  twist 
its  pedicle  is  as  comprehensible  as  the  fact  that  a  good 
weathercock  moves  in  varying  directions  under  the  influence 
of  the  wind.  It  is,  however,  puzzling  to  find  the  spleen,  dis- 
tended Fallopian  tubes,  undescended  testes,  the  pregnant 
uterus,  the  kidneys,  the  ceecum,  and  the  stomach  hable  to 
similar  rotation. 

Ovarian  tumours  of  all  kinds  are  very  liable  to  axial  rota- 
tion, even  in  the  newly  born  (Otto  von  Franque).  Concerning 
its  cause  very  little  is  known.  Various  explanations  have  been 
advanced.  It  has  been  attributed  to  the  alternate  distension 
and  evacuation  of  the  bladder  (Klob),  or  to  the  passage  of 
fseces  through  the  rectum  (Lawson  Tait) ;  to  sudden  move- 
ments, such   as   a   fall,  slip,  or  unusual  exertion  (Thornton). 

2  I  529 


530  TUMOURS   OF    THE   OYABY 

An  important  fact  to  remember  is  the  frequency  with  which 
this  accident  occurs  when  ovarian  cysts  comphcate  preg- 
nancy, and  especially  when  an  ovarian  cyst  complicates  a 
myomatous  uterus  large  enough  to  fill  the  pelvis. 

When  both  ovaries  are  converted  into  cysts  the  risk  of 
twisting  is  nearly  the  same  as  when  pregnancy  and  an  ova- 
rian cyst  are  associated.  When  both  ovaries  are  cystic  and 
pregnancy  ensues,  the  risk  of  axial  rotation  is  more  than 
doubled.  The  torsion  may  occur  early  in  pregnancy  or  be 
delayed  till  delivery  or  miscarriage.  In  one  instance  at 
least,  in  a  case  of  bilateral  ovarian  dermoids,  both  tumours 
had  twisted  their  pedicles  (Doran). 

The  occurrence  of  acute  torsion  immediately  after  de- 
livery is  due  to  the  rapid  diminution  in  the  size  of  the  uterus 
and  to  the  movement  which  this  organ,  as  it  sinks  into  the 
pelvis,  imparts  to  the  tumour.  In  a  case  under  my  own  ob- 
servation, acute  axial  rotation  of  an  ovarian  cyst  as  big  as  a 
fist  was  caused  by  the  movement  and  dragging  of  a  prolapsed 
uterus :  the  rotation  caused  the  tumour  to  be  impacted  low 
in  the  pelvis,  and  the  uterus  remained  outside  the  vagina  and 
could  not  be  reduced  until  the  tumour  had  been  removed. 

Rotation  of  a  cyst  in  the  early  stages  of  pregnancy  is 
probably  due  to  the  gradual  enlargement  of  the  uterus  dis- 
placing the  tumour  upwards  ;  and  as  the  pressure  is  exerted 
upon  one  side  of  the  cyst,  it  would  be  in  a  favourable  position 
to  impart  a  rotatory  motion  to  a  non-adherent  cyst.  The 
amount  of  rotation  varies  greatly.  In  some  cases  the  cyst 
has  only  turned  through  half  a  circle ;  in  others  as  many  as 
twelve  complete  twists  have  been  counted.  The  direction  of 
the  rotation  may  be  from  right  to  left,  or  vice  versa,  but 
cysts  exhibit  a  strong  tendency  to  rotate  towards  the  middle 
line  rather  than  from  it.  Tumours  of  the  right  and  the  left 
side  are  equally  liable  to  torsion.  Small  tumours  twist 
more  freely  than  large  ones,  and  a  long  and  slender  pedicle 
favours  rotation.  The  force  with  which  some  of  the  large 
cysts  rotate  is  very  great,  for  in  some  instances  the  uterus 
is  involved  in  the  twist.  In  one  remarkable  case  the  ovary 
was  caught  in  the  pedicle  of  a  parovarian  cyst  during  rotation 
and  was  divided  (Fig.  278). 

The  effect  of  torsion  on  the  circulation  depends  on  the 


AXIAL  ROTATION 


531 


tightness  of  tlie  twist,  and  this  varies  with  the  thickness  of 
the  pedicle.  The  vessels  in  a  long  thin  pedicle  would  suffer 
obstruction  more  quickly  than  those  in  a  short  thick  one. 
When  a  pedicle  is  torsioned  the  thin-walled  veins  become 
compressed,  whilst  the  more  resilient  arteries  continue  to 
convey  blood  to  the  cyst.  The  result  is  severe  venous  en- 
gorgement, and  this  leads  to  extravasation  of  blood  into  the 
cyst- wall ;  in  many  cases  the  veins  rupture,  and  haemorrhage 
takes  place  into  the  cavity  of  the   cyst.     The   haemorrhage 


rig.  278. — Parovarian  cyst  which  rotated  and  twisted  its  pedicle.     The  ovary  was 
caught  in  the  pedicle  and  divided.     (^Comyns  Berkeley. ) 

may  be  so  profuse  as  to  cause  profound  anaemia,  and  even 
death. 

When  the  venous  circulation  is  completely  arrested  in  con- 
sequence of  torsion,  the  appearance  of  the  cyst  is  very  striking 
and  characteristic.  On  the  abdomen  being  opened  during 
life,  instead  of  the  cyst  presenting  the  famihar  white  glistening 
appearance,  it  has  a  deep,  dark,  lustreless  hue,  which  is  most 
intense  near  its  attachment  to  the  pedicle.  In  milder  degrees 
of  torsion  the  change  in  colour  only  affects  the  base  of  the 
tumour.     The  pedicle  on  the  distal  side  of  the  twist  presents 


532  TUMOURS   OF  THE   OVABT 

the  same  dark  hue,  but  on  the  uterine  side  it  is,  as  a  rule,  of 
natural  tint.  The  contrast  of  colour  in  the  two  parts  of  the 
pedicle  is  very  striking.  The  walls  of  the  cyst  are  thick  and 
succulent ;  the  blood  contained  in  the  cavity,  or  in  the  loculi 
if  multilocular,  may  be  of  a  chocolate  or  of  a  dark-red  colour. 

When  such  a  cyst  is  removed  from  the  body  and  the 
blood  is  allowed  to  drain  away,  or  is  washed  away  by  a  gentle 
stream  of  water,  the  tissues  will  resume  their  natural  colour. 
This  should  be  remembered,  because  some  writers  have 
attributed  the  dark  colour  to  gangrene  of  the  cyst.  This 
is  erroneous ;  gangrene  of  an  ovarian  cyst  is  a  rare  event, 
and  can  only  take  place  when  air  is  admitted  from  without, 
as  during  the  operation  of  tapping,  or  when  intestinal  fluids 
obtain  access  to  it. 

The  usual  effects  of  acute  torsion  of  the  pedicle  are  passive 
congestion,  thrombosis,  extravasation  of  blood  into  the  tissues 
of  the  tumour,  and  necrosis. 

Necrosis  is  localized  death,  in  contrast  to  the  death  of  the 
organism  as  a  whole,  or  "  somatic  death." 

Moist  gangrene  is  necrosis  followed  by  decomposition  and 
putrefaction  of  the  dead  tissues.  When  soft  parts  necrose  in 
situations  where  they  are  accessible  to  putrefactive  organ- 
isms, such  as  the  exterior  of  the  body,  the  lungs,  or  the 
intestinal  tract,  decomposition  rapidly  ensues,  especially  if  the 
parts  contain  much  blood.  In  the  case  of  ovarian  tumours 
with  twisted  pedicles,  not  in  communication  with  the  outer 
air  directly  or  indirectly,  micro-organisms  rarely  gain  access 
to  them. 

It  is  therefore  erroneous  to  describe  as  gangrene  the 
changes  observed  in  cysts  with  torsioned  pedicles.  This  is 
further  illustrated  by  the  circumstance  that  small  ovarian 
tumours  may  be  completely  twisted  from  their  pedicles  and 
subsequently  shrink.  Were  the  changes  in  the  cyst  gan- 
grenous in  character,  general  infection  of  the  peritoneum  and 
death  would  be  the  inevitable  consequences. 

Burden  Sanderson,  in  his  article  on  the  Pathology  of 
Inflammation,  refers  to  the  peculiar  plan  of  emasculating 
animals  known  as  bistournage.  In  this  method  no  instrument 
is  used;  the  testicle  is  freed  from  its  association  with  the 
dartos,  then  twisted  on  the  spermatic  cord  as  on  an  axis,  four 


AXIAL  ROTATION 


533 


or  five  times,  the  whole  manipulation  being  performed  with 
prodigious  rapidity.     If  the  animal  is  killed  afterwards  and 


Fig.   279.— Ovarian   dermoid   containing  hair  and   grease  which  had   twisted   its 

pedicle  many  times. 

*  The  stiimp  of  the  Fallopian  tube. 

the  arteries  are  injected,  it  is  found  that  no  blood  enters  the 
spermatic  artery  beyond  the  twisted  part  of  the  cord.  Con- 
sequently, while  the  surrounding  parts  receive  their  natural 


534  TUMOURS   OF  THE   OVABY 

supply  of  blood  from  the  piidic  artery  and  preserve  their 
vitality,  the  testicle  itself  is  irretrievably  condemned  to  death. 
.We  have  in  the  above  method  practically  a  crucial  experiment, 
which  demonstrates  that  when  a  testicle  is  deprived  of  blood 
in  consequence  of  axial  rotation  it  necroses  and  finally 
atrophies. 

A  perusal  of  the  records  of  cases  described  as  gangrenous 
cysts  indicates  that  the  reporters  have  regarded  the  deep  livid 
hue  of  such  cysts  as  evidence  of  gangrene,  and  that  others 
have  confounded  suppurating  with  gangrenous  cysts. 

Rotation  of  an  ovarian  cyst,  when  it  gives  rise  to  such 
severe  changes  as  have  just  been  considered,  may  be  described 
as  acute  torsion.  It  frequently  happens  that  during  the 
performance  of  ovariotomy  a  thick  pedicle  is  found  twisted 
through  half  or  even  a  complete  circle,  without  producing  an 
appreciable  effect  upon  the  tumour.  In  others,  torsion  takes 
place  so  gradually,  yet  so  completely,  that  the  pedicle  is 
twisted  like  a  rope,  and  not  infrequently  the  pedicle  breaks 
and  the  tumour  becomes  detached  from  its  uterine  connex- 
ions. To  this  variety  the  term  slow  or  chronic  torsion  may 
be  applied.  Its  effects  are  not  less  interesting  than  those 
which  follow  acute  twisting.  When  rotation  occurs  slowly, 
the  walls  of  the  cj^st  inflame  and  adhesions  are  established 
between  the  cyst  and  the  omentum  or  the  parietal  peritoneum; 
such  adhesions  become  vascular  and  maintain  the  vitality  of 
the  C3^st-wall  after  circulation  is  arrested  through  the  pedicle. 
Cysts  have  been  observed  in  all  stages  of  transplantation. 

Acute  torsion  is  more  frequent  in  tumours  of  medium  size  ; 
it  also  occurs  in  smaU  cysts;  but  it  is  the  small  tumours, 
especially  dermoids,  in  which  slow  torsion  takes  place. 

The  dermoid  which  had  undergone  axial  rotation  (Fig.  279) 
had  so  lengthened  its  pedicle  that  the  tumour  sometimes 
rested  in  the  loin  and  resembled  a  very  movable  kidney :  it 
produced  no  pain,  but  annoyed  the  patient  by  its  excursions 
about  the  belly. 

The  symptoms  of  acute  torsion  of  an  ovarian  cyst  are  often 
so  characteristic  as  to  lead  to  a  correct  diagnosis.  When  a 
woman  complams  of  sudden  and  violent  pain  in  the  abdomen, 
accompanied  Avith  vomiting,  and  she  is  known  to  have  an 
ovarian  tumour,  or  she  presents  herself  for  the  first  time  to 


MODES   OF  DEATH  635 

the  surgeon  and  these  signs  are  associated  with  an  abdominal 
swelling  the  physical  signs  of  which  are  indicative  of  an 
ovarian  tumour,  axial  rotation  should  be  suspected.  Should 
the  patient  possess  a  gravid  uterus  as  well  as  an  ovarian  cyst, 
it  is  even  more  probable  that  rotation  has  occurred ;  or  if  she 
has  an  ovarian  tumour  and  has  been  recently  delivered,  this 
is  an  additional  reason  for  suspecting  that  the  symptoms  arise 
from  a  twisted  pedicle. 

Clinical  observations  demonstrate  that  the  predominant 
signs  of  acute  axial  rotation  of  abdominal  tumours  and 
viscera  are  those  common  to  a  strangulated  hernia  minus 
stercoraceous  vomiting. 

Even  the  presence  of  fsecal  vomiting  does  not  always 
negative  the  existence  of  acute  axial  rotation  of  an  ovarian 
tumour,  for  a  loop  of  bowel  is  sometimes  involved  in  the  twist 
and  produces  intestinal  obstruction. 

Suppuration  in  ovarian  dermoids. — When  air  or 
intestinal  fluids  gain  access  to  these  tumours,  then  septic 
infection  with  all  its  attendant  evils  is  the  result,  and 
unless  the  pus  finds  an  outlet  the  individual  dies.  The 
pus  in  a  suppurating  dermoid  sometimes  bursts  into  the 
bowel,  bladder,  vasfina,  or  through  the  abdominal  wall  at 
or  near  the  umbilicus.  When  the  cyst  communicates  with 
the  bladder  it  will  sometimes  entail  very  great  misery,  because 
fragments  of  bone,  teeth,  locks  of  hair,  and  sloughs  become 
impacted  in  the  urethra.  Cystitis  is  an  almost  constant 
accompaniment.  Ovarian  teeth  in  the  bladder  have  formed 
the  nuclei  of  phosphatic  calculi. 

Hair  from  ovarian  dermoids  entering  the  bladder  is  voided 
with  the  urine,  a  condition  of  things  described  by  French 
surgeons  as  inlimiction. 

Rupture. — Ovarian  cysts  of  all  kinds  are  liable  to  burst 
into  the  belly,  either  without  any  obvious  cause  (spontaneous 
rupture),  or  from  violence,  such  as  falls,  blows,  coughing, 
vomiting,  the  manipulation  of  physicians,  or  an  immoderate 
fit  of  laughter. 

Modes  of  death. — Tumours  of  the  ovaries  are  now  so 
promptly  removed  when  discovered  that  there  are  happily 
few  opportunities  of  studying  the  ways  in  which  they  destroy 
life.     The  chief  modes   are  the   following :   (1)  Pressure  on 


536  TUMOURS   OF  THE   OVARY 

the  ureters,  leading  to  hydronephrosis  and  uraemia :  (2) 
cystitis  and  pyelitis ;  (3)  intestinal  obstruction ;  (4)  suppura- 
tion of  the  cyst  and  septic  infection  from  leakage  (peritonitis); 
(5)  haemorrhage  from  rupture  of  the  cyst ;  (6)  axial  rotation 
of  the  tumour;  (7)  impediment  to  delivery;  (8)  epithelial 
infection  of  the  peritoneum,  and  occasionally  dissemination 
(malignancy). 

Treatment. — All    ovarian    cysts    and   tumours   should 
be  removed  entire  at  the  earliest  possible  moment. 

von  Franque,  Otto,    "  Ovarialcyste   mifc  Abdrehung   des   Stiels  beim  Neuge- 

borenen." — Zeitschr.  f.  Geb.,  1900,  xliii.  257. 
Rokitansky,    Prof.,    "  Ueber   der   Strangulation    von   Ovarialtumoren  durcb 

Achsendrehung." — Zeitschr.der  K.K.  GeseUscliaft der  Acrzte inWien,  18G5. 
Sanderson,    Burdon,    "Pathology   of    Inflammation." — Holmes   and   Hulke's 

"  System  of  Surgery,"  i.  84. 


CHAPTER  LIII 

TUMOURS    OF   THE    MALE    GENITAL   GLAND 
(TESTICLE) 

Even  when  divested  of  what  may  be  called  its  adventitious 
tunics,  acquired  as  a  result  of  its  emigration  from  the 
abdominal  cavity  to  a  position  in  the  pouch  of  skin  called 
the  scrotum,  the  testis  is  a  complex  gland,  for  its  ducts,  the 
vasa  efFerentia,  epididymis,  and  vas  deferens,  were  originally 
the  excretory  ducts  of  the  mesonephros  (Wolffian  body).     A 

Paradidymis. 

Kobelt's  tubes. 


Fig.  280. — Diagram  to  show  the  relation  of  the  mesonephros  and  its  ducts  to  the 

adult  testis. 

study  of  the  evolution  of  the  male  secretory  organ  of  verte- 
brates indicates  clearly  enough  that  the  ducts  have  under- 
gone a  change  of  function,  and  their  relation  to  the  testicle 
is  secondary.  An  examination  of  the  embryonic  testis  shows 
that  remnants  of  the  mesonephros  persist  among  the  ducts, 
and  only  a  few  of  the  Wolffian  tubules  are  utilized  by  the 
testicle. 

537 


538 


TUMOURS   OF   THE    TESTIS 


The  relation  of  the  various  embryonic  structures  to  each 
other  is  shown  diagrammatically  in  Fig.  280.  In  the  adult 
it  will  be  seen  that  a  few  of  the  Wolffian  tubules  become  the 
vasa  eff'erentia,  the  remainder  usually  atrophy ;  but  in  many 
individuals  one,  two,  or  more  persist,  usually  as  pedunculated 
cysts  of  small  size  at  the  top  of  the  testicle. 

The  shrunken  remains  of  the  mesonephros  (Wolffian 
body)  sometimes  persist  as  a  collection  of  cfecal  tubes 
furnished  with  epithelium,  lying  among  the  vasa  efferentia 


.  The  secreting  tibsue  of  the  testis. 


Fig. 


The  tumour. 


281. — A  testis  in  section.     The  paradidymis  is  replaced  by  an  adenoma.     The 
secreting  tissue  is  a  flattened  band  at  the  upper  pole  of  the  tumour. 


between  the  epididymis  and  the  testis,  and  often  extending 
a  little  distance  into  the  tissues  of  the  cord.  These  remnants 
are  known  as  the  paradidymis.  Thus,  in  the  male  the 
mesonephros  is  represented  by  the  paradidymis,  its  tubules 
by  the  vasa  efferentia  and  Kobelt's  tubes,  and  its  ducts  by  the 
epididymis  and  vas  deferens. 

The  terminology  of  tumours  of  the  testis  is  very  confusing; 
in  this  work  an  interesting  group  will  be  considered  under  the 
title  of  Cystic  Disease  of  the  Testis,  a  phrase  introduced  by 
Curling  (1853).  This  surgeon  pointed  out  an  important 
feature   connected  with   these   tumours,   namely,   that   they 


CYSTIC  DISEASE 


539 


rise  in  the  tissues  of  the  rete  testis,  a  vestigial  structure 
lying  between  the  body  of  the  testis  and  the  epididymis.  As 
the  tumour  increases  in  size  the  secreting  tissue  of  the  testis 
is  flattened  into  a  mere  stratum  over  its  upper  pole.  There 
are  three  varieties  of  tumour  arising  in  the  paradidymis,  and 
in  their  most  specialized  forms  they  have  received  distinctive 
names — adenoma    testis ;    cystic  disease   of  the  testis  ;    and 


Fig.  282. — A  testis  in  section :  it  is  the  seat  of  a  cystic  tumour  which  arose  in  the 

paradidymis. 

*  The  secreting  tissue  of  the  testis.     (3Iuseum,  Royal  College  of  Surgeons.) 


dermoid  or  teratoma  of  the  testis.  There  are  intermediate 
forms,  and  specimens  occasionally  come  under  observation 
in  which  the  characters  of  the  three  varieties  are  blended. 
Adenoma  testis  in  its  typical  form  (Fig.  281)  is  a  solid 
tumour  composed  of  epithelial  tubules  with  narrow  lumina  ; 
these  epithelial  cylinders  lie  in  juxtaposition  without  the 
intervention  of  connective  tissue.  Tracts  of  hyalin  cartilage 
are  sometimes  present.     Here  and  there,  in  apparently  solid 


Fig.  283.— A  testis  with  the  spermatic  cord  and  the  spermatic  vessels,  removed  by- 
radical  orchidectomy  from  a  man  31  years  of  age.  The  testis  is  shown  in  section. 
A  cystic  tumour  has  grown  between  the  body  of  the  testis  and  its  epididymis. 
The  secreting  tissue  of  the  testis  is  flattened  over  the  upper  pole  of  the  tumour. 


540 


CYSTIC  DISEASE   OF   THE   TESTIS 


541 


tumours,  cysts  due  to  the  dilatation  of  the  tubules  are  seen 
in  the  sections. 

The  cystic  form  is  a  very  striking  tumour.  On  section 
it  is  seen  to  be  made  of  cystic  spaces  greatly  varying  in 
size :  some  are  no  larger  than  a  rape-seed,  and  others  may 
attain  the  size  of  a  hazel-nut  (Fig.  282).  Many  are  distinctly 
tubular,  and  the  cysts  sometimes  communicate  with  each 
other.  The  cysts  are  lined  with  epithelium,  which  may  be 
columnar,  cubical,  or  stratified.  In  some  specimens  occurring 
in  boys,  striated  muscle-tissue  has  been  detected. 


Fig.  284. — A  lymph-node    from  beneatli  the  left  clavicle  enlarged  secondary  to 
a  cystic  tumour  of  the  testis. 

Cystic  disease  of  the  testis  is  sometimes  malignant  and 
infects  the  lymph-glands. 

In  1909  I  removed  the  right  testis  of  a  man  31  years  old 
by  radical  orchidectomy,  and  at  the  same  time  removed  an 
enlarged  lymph-node  lying  on  the  inferior  vena  cava.  This 
gland  was  examined  microscopically ;  it  contained  a  collection 
of  small  cystic  spaces  lined  with  epithelium  identical  with 
that  in  the  testis  (Fig.  283). 

Six  months  later  the  man  again  came  under  observation 
with  a  cystic  tumour  in  the  left  side  of  the  neck  under  the 
sternal  end  of  the  clavicle.  This  was  removed ;  on  section  it 
appeared  transformed  into  cysts  (Fig.  284).     These  were  lined 


542 


TUMOURS   OF  THE   TESTIS 


with  epithelium  like  that  found  in  the  testis.  The  infection 
must  have  travelled  up  the  thoracic  duct.  A  year  later  he 
was  in  good  health. 

The  dermoid  or  teratomatous  tumour  of  the  testis  is 
very  rare,  and  as  striking  in  its  general  naked-eye  features 
as  the  cystic  form,  for  it  contains  hair  and  teeth  {Fig.  285). 
It  is  the  rarest  form  of  all  tumours  of  the  testis.  In  order 
to  give  some  idea  of  its  rarity,  it  may  be  mentioned  that 
during  the   last   thirty  years  only  five  examples  have   been 


Fig.  285. — Embryoma  of  the  testis  in  section.     From   a  Chinese  boy  aged  19,  in 
whom  it  was  congenital.     {Muse/on,  Royal  College  of  Surgeons. ) 


recorded  by  British  surgeons  :  D'Arcy  Power,  1887  ;  Jackson 
Clarke,  1896 ;  Bland-Sutton,  1903 ;  Kuhne,  1908 ;  and 
Barrington,  1910.  The  sources  of  these  tumours  are  inter- 
esting. Clarke's  specimen  was  removed  from  a  Hindu  by 
Lt.-Colonel  C.  M.  J.  Giles ;  my  specimen  was  removed  by 
R.  T.  Booth  from  a  Chinese  student  in  Hankow  (Central 
China) ;  and  Kuhne's  came  from  a  Chinese  boy  aged  4  at 
Tungkau  (China). 

The  cavity  of  the  teratoma  (Fig.  285)  contained  the 
usual  "  embryonal  rudiment  "  embedded  in  sebaceous  matter 
and  loose  hair.     The  rudiment  was  composed  of  bone,  hyalin 


BJSRMOIDS  543 

cartilage,  and  a  miilticuspidate  tooth.  The  testicular  tissue 
formed  a  flattened  stratum  outside  the  wall  of  the  cyst. 

In  its  gross  anatomy  and  structural  details  this  tumour 
reveals  the  usual  features  of  dermoids  growing  in  relation 
with  the  testis.  Some,  it  is  true,  are  more  complex  and  con- 
tain nerve-cells,  as  in  one  very  carefully  reported  case 
examined  by  Cornil :  in  a  "bud"  growing  from  the  cyst- 
wall  a  collection  of  nerve-tissue  containing  ganglion-cells 
was  detected. 

In  its  clinical  details  the  tumour  from  the  Chinese  boy 
did  not  differ  from  its  forerunners.  In  nearly  all  the 
recorded  cases  enlargement  of  the  testis  was  observed  at 
or  shortly  after  birth.  The  tumour  seems  to  have  caused 
little  inconvenience  to  these  boys  ;  indeed,  it  appears  to  lie 
dormant  till  puberty,  then  bruises  and  knocks,  or  abscesses 
and  sinuses,  cause  trouble  and  lead  to  surgical  interference. 

Recent  observations  show  that  testicular  teratomas  are 
even  more  complex  than  these  facts  indicate,  for  Schlagen- 
haufer  discovered  that  some  of  these  tumours  contain  tissue 
indistinguishable  microscopically  from  that  found  in  the 
typical  chorion-epithelioma.  These  observations  have  been 
confirmed  by  other  pathologists. 

Most  of  our  knowledge  of  testicular  dermoids  dates  from 
an  elaborate  article  published  by  Yerneuil  in  1855,  founded 
on  the  reports  of  nine  cases  he  collected  from  the  literature 
of  the  preceding  one  hundred  and  fifty  years,  and  one 
example  which  came  under  his  own  observation.  The  con- 
clusions expressed  in  this  admirable  paper  have  become 
classical,  and  form  the  foundation  of  our  knowledge  of  the 
subject ;  and  even  at  this  date,  nearly  half  a  century  since 
its  publication,  Verneuil's  views  are  reproduced  (frequently 
without  any  reference  to,  and  often  perhaps  in  ignorance  of, 
their  source)  in  monographs  devoted  to  diseases  of  the  male 
genital  organs  and  in  text-books  of  surgery.  It  is  true,  not- 
withstanding the  fact  that  these  tumours  can  now  be  studied 
with  all  the  advantages  of  modern  histologic  methods  and 
differential  staining,  that  we  know  no  more  concerning  their 
pathogenesis  than  Verneuil  knew  ;  and  testicular  dermoids  re- 
main with  us,  as  they  were  with  him,  pathological  curiosities. 

It  is  also  noteworthy  that  dermoids  of  the  testis,  accordmg 


544 


TUMOURS  OF  THE    TESTIS 


to  all  the  available  records,  are  unilateral,  whereas  ovarian 
dermoids  are  very  frequently  bilateral. 

Verneuil  shows  in  the  title  of  his  paper  ("  Memoire  sur 
rinclusion  scrotale  et  testiculaire  ") — which  title,  he  relates, 
was  selected  as  conveying  precisely  the  view  he  held  in  regard 
to  the  nature  of  the  disease — that  he  believed  testicular 
dermoids  belongfed  to  the  class  of  double  monsters  known  as 


Fig.  286.— Undescended  testis  removed  from  a  colt.     It  is  associated  with  a  large 
dermoid  containing  grease  and  coarse  hair  Uke  that  of  the  mane  and  tail. 

parasitic  foetuses.  A  study  of  the  records  published  during 
the  last  ten  years  supports  Verneuil's  contention  that  der- 
moids within  the  tunica  vaginalis,  though  attached  to  and 
often  intimately  associated  with  the  testis,  are  not  really  "  of 
the  testis "  in  its  strictest  sense :  they  do  not  arise  from 
transformation  of  testicular  tissue.  In  some  of  the  cases  the 
dermoid  was  attached  to  the  gland  by  such  slender  con- 
nexions that  the  surgeon  succeeded  in  detaching  the  tumour 
and  preserved  the  testis.     Admirable  conservative  operations 


DERMOIDS 


545 


of  this  character  are  recorded  by  Cornil  and  Berger,  Chevassu, 
and  Rechis. 

These  typical  dermoids  differ  from  the  adenomatous  and 
cystic  forms  in  being  benign. 

Horses  are  especially  liable  to  testicular  dermoids,  a  fact 
known  to  Verneuil;  and  they  are  often  associated  with  unde- 
scended testes.  Like  typical  ovarian  dermoids,  they  possess 
an  ill-developed  embryonal  rudiment  contained  in  a  cyst, 
covered  with  pilose  skin  and  stuffed  with  loose  hair,  grease, 
and  occasionally  teeth  resembling  equine  incisors.  The  hair 
resembles  that  of  the  mane  or  tail  (Fig.  286).     The  relation 


Fig.  287. — Hyalin  cartilage  in  the  stroma  of  a  recurrent  carcinoma  of  the  rectum. 

{After  Foulerton.) 

of  the  dermoid  to  the  paradidymis  is  the  same  in  horses  as 
in  man. 

The  occurrence  of  dermoids  in  the  undescended  testes  of 
horses  has  a  clinical  interest,  for,  as  I  have  already  mentioned, 
in  the  records  of  the  human  cases,  although  the  unusual  size 
of  the  testis  was  invariably  noticed  at  birth,  yet  it  did  not 
interfere  with  the  descent  of  the  organ.  There  is  a  case 
recorded  by  Delbet  in  which  a  testis,  retained  at  birth  in  the 
inguinal  ring,  gradually  descended  to  the  scrotum  ;  subse- 
quently it  was  found  to  be  occupied  by  a  dermoid.  In  this 
respect  horses  and  boys  differ  very  markedly,  but  they 
agree  in  the  following  points :  although  a  dermoid  may  be 
2  J 


546 


TUMOURS   OF   THE   TESTIS 


attached  to,  or  incorporated  with,  either  a  right  or  a  left 
testis  in  fairly  equal  proportions,  an  example  of  bilateral 
testicular  dermoid  has  yet  to  be  recorded. 

The  frequent  presence  of  hyalin  cartilage  in  malignant 
tumours  of  the  testis  has  attracted  the  attention  of  many 
writers.  In  some  cases  cartilage  forms  the  chief  portion  of 
the  tumour  and  its  metastases ;  several  investigators  have 
endeavoured  to  determine  the  nature  of  the  chondrification. 
In  consequence  of  the  frequency  with  which  cartilage  is 
found  in  these  tumours  it  has  been  customary  to  class 
them  as  sarcomas. 

Foulerton   has  shown   that  many  malignant  tumours  of 


Spermatic  cord. 

Epididymis. 

Testis. 

Tunica  vaginalis. 


Portion  of  tmnour 
within  tlie  tunica 
vaginalis. 


—   The  tumour. 


Fig.  288. — Testicle  from  a  child  with  a  tumour  growing  from  the  lower  pole, 
which  contained  muscle -spindles,  some  of  which  were  transversely  striated. 
{After  Naumann.) 

the  testis  are  in  structure  and  pathologic  tendency  carcino- 
mas ;  and  he  points  out  that  Paget's  classic  specimen  when 
re-examined  by  Kanthack  and  Pigg  was  found  to  be  a  carci- 
noma. He  is  also  of  opinion  that  writers  on  surgical  pathology 
are  in  the  habit  of  considering  the  presence  of  hyalin  cartilage 
as  evidence  that  the  tumour  is  a  sarcoma,  and  that  chondri- 
fication of  tissue  in  typical  cancers  has  not  been  sufficiently 
considered.  He  has,  however,  proved  in  an  unequivocal  way 
that  hyalin  cartilage  occurs  in  association  with  cancer  of  the 
rectum  (Fig.  287),  and  has  proved  its  presence  in  a  lymph- 
gland  infected  with  carcinoma.  Foulerton  is  also  of  opinion 
that  many,  if  not  the  majority,  of  malign  tumours  of  the  testis 


SARCOMA 


547 


are  more  properly  classed  with  the  carcinomas  than  with  the 
sarcomas  ;  at  the  same  time  he  is  in  agreement  with  preceding 
observers  that  malignant  tumours  of  the  testis  arise  in  the 
hilum  of  this  organ. 

Tumours  containing  transversely  striated  muscle-cells 
sometimes  grow  from  the  testicle  (Fig.  288). 

Sarcomas. — In  addition  to  teratomas  arising  in  the 
paradidymis,   malignant    tumours    pos'sessing   the    structure 


Fig.  289. — Testicle  in  section.  A,  Epididymis  ;  B,  sarcomatous  tissue  ;  c,  remnant  of 
the  body  of  the  oi'gan.  From  a  man  aged  28,  who  had  noticed  an  enlarge- 
ment of  his  testicle  for  eight  months.  Castration  was  performed.  He  died 
ten  months  later. 

and  clinical  features  of  sarcomas  arise  in  the  body  of  the 
testis.  Such  tumours  have  oat-shaped  cells,  or  round  cells, 
and  some  have  the  characters  of  lympho-sarcomas. 

Whatever  view  pathologists  may  take  of  the  structural 
characters  of  testicular  tumours,  the  surgeon  never  forgets  the 
grim  reality  that  the  majority  of  these  complex  growths 
quickly  destroy  life  (Fig.  289). 

One  of  the  most  prominent  clinical  features  of  malignant 


548 j  iTUMOUBS  OF   THE   TESTIS 

tumours  of  the  testis  is  the  rapidity  and  extent  of  the  lymph- 
gland  infection.  The  great  size  which  the  lumbar  lymph- 
glands  attain  in  some  patients  is  truly  astonishing.  The 
connective  tissue  in  the  hilum  of  the  testis  is  described  as 
consisting  "  of  fine  fasciculi  and  laminae  of  areolar  tissue, 
these  being  covered  by  and  partly  composed  of  flattened 
epithelioid  cells.  Between  the  laminae  and  fasciculi  are  large 
cleft-like  spaces,  containing  lymph  and  almost  everywhere 
enclosing  the  basement  of  the  tubules.  If  these  spaces  are 
injected  by  the  puncture  method,  the  injecting  fluid  flows 
away  by  the  lymphatics  of  the  spermatic  cord  "  (Quain).  This 
free  lymphatic  communication  of  the  hilum-territory  explains 
the  extreme  facility  with  which  the  abdominal  lymph-system 
can  be  infected.  Dissemination  of  testicular  sarcoma  is  some- 
times brought  about  by  the  veins,  for  it  occasionally  happens 
that  secondary  nodules  are  found  in  the  skin,  lungs  and 
other  viscera,  nevertheless  the  prevailing  mode  of  infection  is 
by  the  lymphatics.  This  has  led  several  investigators  to 
study  the  relation  of  these  vessels  and  their  associated  nodes 
to  malignant  tumours  of  the  testis.  Most  made  a  study 
of  this  question  with  the  aid  of  fine  injections,  and  the 
result  of  his  inquiries  is  shown  in  Fig.  290.  A  study  of 
the  relations  of  these  lymph-glands  to  the  cisterna  chyli 
makes  it  clear  how  a  malignant  tumour  in  the  testis  leads 
to  enlargements  of  the  left  supraclavicular  lymph-nodes. 
Jamieson  and  Dobson  have  also  made  a  careful  study  of  this 
matter  (1910). 

Frequency  of  malignant  tumours  of  the  testis. — During 
the  year  1907  twelve  testes  were  removed  in  the  chief  hos- 
pitals of  London  for  the  relief  of  malignant  tumours.  The 
distribution  of  the  cases  is  as  follows :  London,  3 ;  St.  Bar- 
tholomew's, 2  ;  Great  Northern,  2  ;  Charing  Cross,  1 ;  Guy's,  1  ; 
St.  George's,  1 ;  University  College,  1 ;  Westminster,  1.  At  the 
Middlesex,  Cancer,  Royal  Free,  St.  Peter's,  St.  Mary's,  and 
St.  Thomas's  there  was  none. 

Malignant  disease  in  retained  testes. — It  is  commonly 
believed  that  retained  testes  are  more  liable  to  malignant 
disease  than  those  properly  lodged  in  the  scrotum.  This 
is  one  of  those  articles  of  surgical  faith  very  difficult  to  affirm 
or  to  deny.      In  1909  there  were  fourteen  examples  available 


GANGER  OF  R-ETAINED   TESTIS 


549 


for  study  in  the  metropolitan  museums.  The  youngest  patient 
was  20,  the  eldest  55.  Some  of  the  tumours  were  large ;  for 
example,  Stabb  removed  one  as  big  as  an  ostrich's  Qgg.  In 
a  few  of  these  cases  the  testis  was  retained  in  the  abdomen, 
but  in  most  instances  it  had  entered  the  inguinal  canal 
When  the  tumour  lies  in  the  abdomen  its  ovoid  shape  and 
lateral  position  have  led  the  surgeon  in  at  least  one  instance 
to  regard  the  tumour  as  an  enlarged  kidney. 

Russell  Howard  has  made  a  most  satisfactory  contribution 
to  the  question  of  the  increased  liability  of  a  retained  testis 


Fig.  290.— Diagram  showing  the  position  and  relations  of  the  lymph-glands 
associated  with  the  testicles.  The  results  were  obtained  by  means  of  fine 
injections.     {After  Most.) 

to  become  the  seat  of  malignant  disease.  He  states  that,  in  a 
period  of  twenty  years,  fifty-seven  consecutive  cases  of  malig- 
nant disease  of  the  testis  were  treated  in  the  London  Hospital : 
the  malignancy  of  the  tumours  was  substantiated  by  a  micro- 
scopic examination.  Among  this  number,  in  nine  cases  the 
testis  was  retained  in  the  inguinal  canal,  giving  a  proportion 
of  nearly  16  per  cent.  This  is  certainly  a  higher  proportion 
than  obtains  in  men  with  normally  descended  testes. 

In  addition  to  malignant  disease  occurring   in   retained 
testes,  mention  must  be  made  of  cancer  and  sarcoma  arising 


550  TUMOURS   OF   THE   TESTIS 

in  the  ill-developed  gonads  of  individuals  with  their  genitalia 
so  malformed  as  to  come  into  the  class  known  as  pseudo- 
hermaphrodites. 

This  matter  has  been  investigated  by  Pick  and  Zacharias. 
Thirty-five  cases  have  been  reported.  It  is  to  me  a  matter  of 
great  interest  to  learn  that  the  gonads  of  pseudo-hermaphro- 
dites are  so  liable  to  be  the  seat  of  teratomas.  In  1887 
I  expressed  the  opinion  that  testicular  dermoids  probably 
arise  in  ovarian  tissue  entangled  in  the  paradidymis. 

Clinical  features. — The  clinical  recognition  of  malignant 
tumours  of  the  testis  is  not  by  any  means  a  simple  matter ; 
it  is  often  impossible  to  distinguish  between  a  hsematocele 
and  a  solid  tumour.  The  points  on  which  it  is  best  to  rely 
are  the  weight  of  the  tumour  and  absence  of  inflammation, 
syphilis,  and  translucency.  Some  sarcomas  are  intensely 
hard  ;  others  are  soft,  and  almost  fluctuate  ;  most  of  them  are 
painless,  but  a  few  are  the  seat  of  continual  pain. 

Treatment. — A  study  of  the  effects  of  operation  for  the 
cure  of  tumours  of  the  testis  is  very  instructive,  as  it  exhibits 
malignant  disease  in  some  of  its  worst  aspects.  Castration, 
save  in  very  exceptional  cases,  is  one  of  the  safest  operations 
in  surgery.  In  the  early  stages  of  sarcoma  the  diseased  testis 
can  be  completely  removed.  Kecurrence  in  the  wound  or 
stump  is  an  unusual  event;  but  dissemination,  due  to  in- 
fection of  the  lumbar  lymph-glands,  destroys  more  than  half 
the  patients  within  a  year  of  the  operation.  These  glands  are 
in  close  relation  with  the  inferior  vena  cava  and  the  ab- 
dominal aorta,  and  the  intimate  association  with  these  blood- 
vessels was  regarded  as  an  obstacle  to  their  removal.  In  spite 
of  this,  cancerous  lumbar  glands  have  been  extirpated  with 
success. 

With  the  hope  of  improving  these  results,  I  introduced 
(1909)  a  method  of  "radical  orchidectomy "  by  which  the 
testicle,  the  spermatic  cord  and  its  veins  are  completely 
removed.  The  free  incision  necessary  for  the  removal  of  the 
spermatic  veins  allows  the  surgeon  to  extirpate  the  lymph- 
nodes  in  the  abdomen  around  the  aorta  and  vena  cava. 
Russell  HoAvard  has  also  had  a  successful  casein  a  boy  (1910). 

Encysted  hydrocele  of  the  testis  (spermatocele). — The 
cysts  to  which  the  term  "  encysted  hydrocele  of  the  testicle  " 


SPERMATOCELES  651 

should  be  applied  arise  sometimes  in  the  vasa  efferentia  ot 
the  testis  and  sometimes  in  Kobelt's  tubes,  and  it  is  a  curious 
fact  that  these  cysts  occur  in  those  structures  which  in  the 
female  give  rise  to  parovarian  cysts.  As  encysted  hydroceles 
in  the  male  and  parovarian  cysts  in  the  female  arise  in  homo- 
logous organs,  these  cysts  are  morphologically  homologous. 

Encysted  hydroceles  are  always  closely  associated  with  the 
testis,  and  lie  outside  its  tunica  vaginalis,  but  they  may  pro- 
ject into  the  cavity  of  this  sac.  Occasionally  a  hydrocele  of 
the  tunica  vaginalis  is  associated  with  an  encysted  hydrocele. 

When  an  encysted  hydrocele  is  very  large  it  may  so  over- 
lap the  testis  that  it  is  difficult  to  differentiate  between  it  and 
a  hydrocele  of  the  tunica  vaginalis,  until  actual  dissection  in 
the  course  of  an  operation  shows  that  the  cyst  is  independent 
of  this  tunic. 

The  lining  epithelium  of  such  cysts  may  be  of  the  strati- 
fied, cubical,  columnar,  or  even  of  the  ciliated  variety.  The 
cysts  contain  fluid,  which  may  be  clear,  or  white  like  milk, 
due  to  the  presence  of  fat  ;  sometimes  spermatozoa  are 
present ;  or  the  fluid  may  be  blood-stained.  Cysts  containing 
semen  are  sometimes  called  spermatoceles.  In  size  these 
cysts  vary  greatly.  As  a  rule  they  do  not  exceed  the  dimen- 
sions of  an  egg,  and  often  are  much  smaller. 

An  encysted  hydrocele  must  not  be  confounded  with  a 
cyst  arising  in  an  unobliterated  funicular  process. 

In  addition  to  the  sessile  form  of  encysted  hydrocele  of 
the  testis  there  is  a  pedunculated  variety  which  is  usually 
described  as  a  supernumerary  hydatid  of  Morgagni.  These 
cysts  rarely  exceed  a  cherry  in  size,  and  arise  in  Kobelt's 
tubules.  As  a  rule  only  one  cyst  is  present,  but  two  or  three 
are  not  uncommon.  Sometimes  they  will,  like  the  hydatid 
of  Morgagni,  project  into  the  cavity  of  the  tunica  vaginalis. 
These  small  bodies  interest  the  morphologist ;  to  the  mere 
surgeon  they  are  only  curiosities. 

Literature. — It  is  an  interesting  feature  of  writings  con- 
cerning dermoids  of  the  testis  that  the  majority  of  the 
observations,  certainly  the  best  among  them,  have  been  the 
work  of  French  surgical  writers.  It  would  seem  that  the 
classical  monograph  of  Verneuil  gave  the  subject  a  French 
domicile. 


552  TUMOUES   OF   TEE    TESTIS 

Barrington,  F.  J.  F.,  "A  Demoid  Cyst  of  the  Testicle."— iarace^^,  1910,  ii.  460. 
Bland-Sutton,  J.,  "An  Essay  on  Dermoids  of  the  Testis."— Arch,  of  Middx. 

Ifosp.,  1903,  i.  19. 
Bland-Sutton,   J.,    "An   Improved   Method    of    removing    the   Testicle    and 

Spermatic  Cord  for  Malignant  Bise-dse."— Lancet,  1909,  i.  1406. 
Bland-Sutton,  J.,  "  The  Value  of  the  Undescended  Testis." — Pract.,  1910,  p.  i. 
Bland-Sutton,  J.,  Erasmus  Wilson  Lectures. — Lancet,  1887,  i.  256. 
Chevassu,  M.,  "  Tumours  du  Testicule,"  Paris,  1906. 
Cooper,  A.,  "  Diseases  of  the  Testes,"  1830. 
Comil  and  Berger. — Bull,  de  V Acad,  de  Med.,  1885,  xiv.  275. 
Curling,  T.  B.,  "  Observations  on  Cystic  Disease  of  the  Testicle." — Med.-Chir. 

Trans.,  1853,  xxxvi.  449. 
Foulerton,  A.  G.  R.,  "  Carcinoma  of  the  Testicle."— ia^cei;,  1905,  ii.  1827. 
Hobday,  "The  Castration  of  Cryptorchid  Horses,''  London,  1903. 
Howard,  Russell,  "  Malignant  Disease  of  the  Testis."- -Prac?;.,  1907,  p.  794, 
Howard,  Russell,  "  A  Radical  Operation  for  Malignant  Disease  of  the  Testis." — 

Lancet,  1910,  ii.  1406. 
Hutchinson,  J.,  jun.,  "  Sarcoma  of  the  Testicle." — Trans.  Path.  Soc,  1889,  xl. 

193. 
Jamieson,  J.  K,  and  Dobson,  J.  F.,  "  The  Lymphatics  of  the  Testicle." — Lancet, 

1910,  i.  493. 
Kanthack  and  Pigg,  S.,    "  Malignant   Enchondroma   of   the   Testis." — Trans. 

Path.  Soc,  1827,  xlviii. 
Kuhne,  J.  E.,  "Rare   Tumour   of   the   TesticlQ.'''—  China  Med.  Journ.,  1908, 

p.  79. 
Most,   "  Ueber  maligne  Hodengeschwiilste  und  ihre  Metastasen." — Virchow's 

Arch.,  1894,  cliv.  138. 
Naumann,  Virchow's  Arch.,  ciii.  497. 
Paget,  Sir  James,  "  Account  of  a  Growth  of  Cartilage  in  a  Testicle  and  its 

Lymphatics  and  other  Parts." — Med.-Chrr.  Trans.,  xxxviii.  247. 
Schlagenhaufer,  Fr,  "  Ueber  das  vorkommen  Chorionepitheliom  und  trauben 

molenartigen  VVucherungen  in  Teratomen." —  Wien.  Mm.  Woch.,  May,  1902, 

Nos.  22,  25. 
Verneuil,  "  Memoire  sur  I'lnclusion  Scrotale  et  Testiculaire." — Arch.  Gen.  de 

Med.,  1855,  S^e  serie,  v.  641,  and  vi.  21,  191,  299. 
Wilms,  "  Die  teratoiden  Geschwiilste  des  Hodens." — Ziegler's  Beit.  f.  path. 

Anat.,  xix.  233. 
Zacharias,  P.,    "  Beitrage  zur  Kenntniss   der   Geschwulst  biklungen   an  der 

keiindrusen   von  Pseudohermaphroditen." — Arch.  f.   Gyn.,  1909,  Ixxxviii. 

506. 


CHAPTER    LIV 

HETEROTOPIC    TEETH 

Among  mammals  the  normal  situation  for  teeth  is  the 
mouth  (buccal  cavity),  but  under  pathologic  and  teratologic 
conditions  they  arise  in  such  unexpected  situations  as  the 
ovary,  testis,  rectuui,  neck  and  pharynx,  in  man,  and  in 
connexion  with  the  tympanum  of  horses  (mastoid  teeth). 
Among  heterotopic  teeth  those  found  in  ovarian  dermoids 
(embryomas)  are  the  best  known,  and  have  been  the  subject 
of  several  careful  investigations. 

Ovarian  teeth. — A  large  proportion  of  ovarian  dermoids 
contain  teeth.  In  number  they  vary  greatly.  Sometimes  only 
two  or  three  are  found ;  in  others,  twenty  or  more  may  be 
counted.  Two  hundred  teeth  have  been  counted  in  a  multi- 
locular  dermoid,  but  it  is  an  unusual  number.  The  teeth  may 
be  embedded  in  loose,  ill-formed  bone,  or  project  from  a  flat 
osseous  plate  like  nails  driven  through  a  piece  of  thin  wood 
(Fig.  291).  Often  the  roots  of  ovarian  teeth  are  embedded  in 
soft  tissue,  or  the  entire  teeth  remain  hidden  in  crypts  or 
cysts.  When  the  crown  projects  boldly  the  neck  of  the  tooth 
may  be  surrounded  with  pink  tissue  resembling  the  gums. 

Teeth  occur  more  frequently  in  ovarian  dermoids  than 
would  be  gathered  from  the  current  descriptions.  Unless  the 
teeth  are  actually  erupted  the  surgeon  may  fail  to  notice  them 
until  he  makes,  or  orders  to  be  made,  a  careful  dissection  of 
the  dermoid.  On  several  occasions  I  have  astonished  my 
assistants  by  directing  a  dermoid  in  which  no  dental  structures 
were  obvious  to  be  destroyed  by  prolonged  boiling:  when 
the  residue  was  examined  many  (sometimes  twenty  or  thirty) 
teeth  were  found. 

The  teeth  are  not  scattered  irregularly  through  the 
dermoid  unless  present  in  very  great  number,  but  are  collected 
in  one  or  more  groups ;    they  vary  in  shape  and  resemble 

553 


554 


HETEROTOPIC  TEETH 


incisors,  canines,  and  supernumerary  teeth.  The  root  is 
usually  single  ;  teeth  with  more  than  one  root,  or  with  a 
bifurcated  root,  are  very-rare.  When  the  crown  is  simple  the 
root  is  long;    multicuspidate  teeth  have  short  roots. 

Ovarian    teeth    are   composed   of    enamel    and   dentine ; 


Fig.  291. — Cluster  of  ovarian  teeth  embedded  in  bone. 


Fig.  292.— Developing  ovarian  tooth,  showing  the  enamel- organ.    From 
an  adult  vroman. 


cementum  is  by  no  means  constant.  The  enamel  is  lodged 
on  the  crown  in  lumps  or  hummocks,  with  deep  ravines 
extending  to  the  dentine.  The  enamel  prisms  run  in  all 
directions.  The  pulp  is  very  irregular ;  some  of  the  teeth, 
especially  those  resembling  incisors  and  canines,  may  lack  a 
central  chamber.     In  a  multicuspidate  tooth  the  pulp-chamber 


OVARIAN  TEETH 


555 


is  of  fair  size.  In  some  the  pulp  is  converted  into  secondary- 
dentine  (Fig.  293);  in  others  it  is  full  of  fat-globules.  The 
presence  of  nerves  in  the  pulps  of  ovarian  teeth  was  asserted 
by  Salter,  and  tissue  resembling  nerve-fibrils  may  be  detected 
in  pulp  suitably  prepared.  Ovarian  teeth  develop  on  the 
same  principle  as  normal  teeth  (Figs.  292,  294). 


Fig.  293. — Microscopic  characters  of 
a  multicuspidate  and  bicuspidate 
ovarian  tooth. 


Fig.  294.— Germ  of  an  ovarian  tooth. 
E,  Enamel  organ ;  p,  papilla. 


For  several  years  I  made  a  series  of  observations  in  order 
to  determine  if  the  development  and  eruption  of  ovarian  teeth 
is  in  any  way  influenced  by  age,  and  to  ascertain  if,  like 
the  hair  of  dermoids,  they  are  shed  in  old  age.  The  evidence 
proved  that  the  development  of  ovarian  teeth  is  uninfluenced 
by  age :  for  example,  a  dermoid  the  size  of  a  tennis-ball,  from 
a  girl  6  years  of  age,  contained  many  teeth,  six  of  which  were 


556 


HETEBOTOPIG   TEETH 


fully  erupted ;  whereas  an  ovarian  dermoid  from  a  woman  in 
middle  life  contained  germs  of  teeth  in  great  abundance,  but 
none  had  reached   the  stagfe  of  calcification. 

Mastoid   (tympanic)  teeth  in   horses. — The  occurrence 


Fig.  29.5.— Two  dental  masses  successfully  removed  from  the  temporal  fossa  of  the 
mare  represented  in  Fig.  297.  The  larger  tumour,  A,  is  shown  in  section  to 
display  the  enamel  strata ;  it  weighed  175  grm.  The  smaller  body,  c, 
weighed  44  grm.  ;    it  is  also  shown  in  section,  b. 

of  teeth  in  the  mastoid  portion  of  the  temporal  bone  in  horses 
has  been  known  for  upwards  of  a  century,  and  specimens  of 
these  curious  teeth  exist  in  many  veterinary  museums.  The 
number  of  teeth  varies ;  as  a  rule  one  tooth  is  present,  stuck 
like  a  peg  in  the  bone.     It  is  not  uncommon  to  find  two, 


MASTOID   TESTS 


557 


and  in  rare  instances  four  teeth.  Mastoid  teeth  are  very 
misshapen,  and  usually  of  the  molar  type ;  often  they  are 
such  ill-fornied  lumps  as  to  come  under  the  denomination 
odontomes;  indeed,  Broca  included  these  bodies  among  his 
odontomes  heterotopiques  (Fig.  295).     Mastoid  teeth  possess 


Fig.  296. — The  tympanic  region  of  a  horse's  skull  with  a  cluster  of  teeth. 

the  three  familiar  dental  tissues — enamel,  dentine,  and 
cementum.  A  careful  examination  of  the  very  few  available 
specimens  in  which  the  skull  has  been  preserved  with  the 
mastoid  teeth  in  position  shows  that  they  arise  in  relation  with 
the  tympanum,  and  especially  with  that  part  of  it  known  as 
the  attic.  This  is  true  of  a  specimen  in  the  museum  of  the 
Royal   Veterinary  College,  London,  in  which  a  solitary  tooth 


558  HETEBOTOPIG    TEETH 

stands  out  from  tlie  remains  of  its  bony  capsule,  the  roots 
of  the  tooth  being  lodged  in  the  tympanic  attic. 

Owing  to  the  kindness  of  Professor  Devvar  I  was  able 
to  study  carefully  a  skull  with  the  teeth  in  position  (Fig.  296). 
In  this  specimen  the  teeth  are  not  lodged  in  sockets,  but 
encysted  by  an  incomplete  bony  capsule,  in  the  mastoid 
portion  of  the  temporal  bone,  especially  in  that  part  imme- 
diately overlapped  by  the  squamosal.  The  cluster  of  teeth 
has  markedly  compressed  the  external  auditory  meatus. 
The  tumour  has  deformed  the  interior  of  the  cranium,  and 
an  uncovered  portion  of  tooth  projects  into  the  cerebellar 
fossa.  During  life  it  was  probably  excluded  by  the  dura 
mater.  It  is  impossible  to  determine  accurately  the  number 
of  separate  dental  bodies  in  this  specimen  without  destroying 
it,  but  I  feel  sure  there  are  at  least  four  separate  pieces. 

There  is  no  satisfactory  explanation  available  as  to  the 
origin  of  these  teeth.  There  is,  one  would  certainly  imagine, 
some  morphological  reason  for  their  localization  in  the 
temporal  bone,  and,  as  the  drawings  show,  they  have 
peculiarities  in  shape  and  size  which  should  serve  for  their 
ready  recognition,  and  enable  us  at  once  to  distinguish  them 
from  testicular  or  ovarian  teeth. 

Before  it  is  possible  to  make  any  decisive  statement  in 
regard  to  the  nature  of  the  mastoid  teeth  of  horses,  it  is  very 
desirable  to  obtain  facts  concerning  their  anatomical  relation- 
ship with  the  soft  parts. 

Mastoid  teeth  are  troublesome  to  horses,  and  give  rise  to 
some  interesting  clinical  conditions.  The  horse  is  usually 
brought  to  the  veterinary  surgeon  on  account  of  a  swelling, 
but  more  frequently  a  sinus,  near  the  base  ■  of  the  auricle. 
When  a  probe  is  passed  along  the  sinus  it  comes  in  contact 
with  a  tooth.  The  recorded  cases  of  this  disease  fail  to  make 
it  clear  whether  the  sinus  is  congenital  or  is  a  consequence 
of  suppuration  as  the  tooth  develops.  Heusinger,  in  an 
admirable  paper  on  cervical  fistulse,  regards  them  as  per- 
sistent branchial  fistulse,  and  states  that  they  are  more 
frequent  in  carriage-horses  (Luxuspferde)  than  in  draught- 
horses,  as  the  secretion  from  the  sinus  soils  the  surrounding 
skin  and  attracts  the  attention  of  the  grooms.  This  sinus 
is  very  constantly  associated  with  mastoid  teeth  in  foals  as 


GEBVIGAL   TEETH  559 

well  as  in  adult  and  aged  horses.  The  veterinarian  usually 
treats  these  cases  in  a  summary  manner,  for  he  enlarges 
the  sinus  and,  ascertaining  the  exact  position  of  the  tooth, 
extracts  it  by  forceps  or  by  a  chisel  and  mallet ;  he  then 
stuffs  the  cavity  with  antiseptic  gauze,  and  encourages  it  to 
become  obliterated  by  granulation.  A  study  of  the  character 
and  position  of  these  teeth  shows  that  their  removal  is  some- 
times attended  with  difficulty,  certainly  with  grave  danger  to 
the  horse,  and  occasionally  their  extraction  is  impracticable. 


Fig.  297. — Head  of  a  van  mare  witli  a  sinus  leading  to  a  mastoid  tooth.     The 
drooping  lip  shows  that  there  was  paralysis  of  the  facial  nerve. 

Cases   are   known   in  which  horses   have   died   from   septic 
meningitis,  the  result  of  suppuration  around  the  teeth. 

Cervical  teeth  in  sheep. — Sheep  are  liable  to  a  peculiar 
anomaly  in  the  immediate  neighbourhood  of  the  ear,  which 
consists  of  a  fistula  opening  near  its  base ;  but  its  skin 
edge  is  invariably  surmounted  by  an  incisor  tooth.  The 
first  impression  is  that  the  opening  represents  a  persistent 
branchial  fistula,  but  in  man  teeth  are  not  associated  with 
these  fistulse.  Congenital  cervical  fistulte  in  sheep  have 
received   careful    attention,   and    these    investigations    show 


560 


HETEROTOPIC    TEETH 


that  the  abnormal  orifice  is  an  accessary  mouth.  In  an 
example  which  came  under  my  notice  (Fig.  298)  the  tooth, 
which  had  the  characters  of  a  temporary  incisor,  is  lodged 
in  a  bony  pedicle  surrounded  by  mucous  membrane  of  the 
same  features  as  the  gums,  and  the  cutaneous  recess  in  which 
it  is  accommodated  presents,  in  the  aspect  which  is  in  contact 
with  the  tooth,  a  number  of  processes  resembling  the  papillae 


Auditory  meatus 


Accessary  mouth 


Fiff.  298. Head  of  a  sheep  with  a  cervical  teratoma.     In  the  lower  figure  the 

teratoma  is  shown  of  natural  size. 

on  the  sheep's  lips,  and  the  arrangement  of  the  wool  on  the 
outer  surface  of  this  accessary  lip  is  identical  with  that 
covering  its  normal  hp.  This  specimen  by  itself  is  some- 
what puzzling,  but  a  wider  survey  of  the  question  adds  a 
special  interest  to  it. 

Gurlt  had  the  opportunity  of  studying  several  examples 
which  enabled  him  to  prove  conclusively  the  nature  of  this 
condition,  and  in  one  of  his  specimens  two  temporary  incisors 


CERVICAL   TEETH 


661 


were  lodofed  in  a  miniature  but  unmistakable  mandible,  and 
associated  with  a  tongue  of  corresponding  size.  The  fistulous 
track  communicated  with  the  pharynx.  When  the  animal 
drank,  some  of  the  fluid  escaped  through  the  fistula. 

Without  entering  too  fully  into  the  details  of  this  matter, 
the  revelation  afforded  by  a  thorough  anatomical  study  of 
the  specimens  amounts  to  this : — 

The  cervical  teeth  and  the  associated  structures  are  the 
remnants  of  an  attached  or  'parasitic  foetus,  and  the  cuta- 
neous opening  represents  its  mouth. 

It  is  rare  for  an  animal  with  one  of  these  accessary  mouths 


Fig.  '299. — Head  of  a  cross-bred  Devon  cow  with  a  teratoma  attached  to  its  throat. 
A  cane  passed  through  the  fistula  a  entered  the  pharynx  of  the  cow. 


to  come  under  the  notice  of  a  trained  observer,  so  I  gladly 
avail  myself  of  the  notes  taken  by  Mr.  Wilson,  a  veterinary 
surgeon,  concerning  a  lamb.  Some  few  days  after  the  lamb 
was  born,  the  shepherd  noticed  that  the  wool  on  the  right 
shoulder  was  saturated  with  milk.  He  carefully  watched  the 
lamb  suckling,  and  on  close  examination  discovered  a  slit 
behind  the  mandible,  through  which  the  milk  issued.  He  drew 
his  master's  attention  to  this,  and  the  latter,  to  his  astonish- 
ment, found  a  rudimentary  tongue  and  jaw  covered  with  a 
lip:  naturally,  he  kept  the  animal  alive  out  of  curiosity.  When 
the  lamb  was  weaned  and  turned  out  on  pasture  land  there 
was  always  a  food-stained  condition  of  the  wool  around  the 
2  K 


562  HETEROTOPIC    TEETH 

opening ;  the  animal  appeared  to  maintain  a  decent  con- 
dition. When  turned  out  in  the  winter  it  lost  the  use  of  its 
front  legs,  and  was  taken  to  the  farm  buildings,  kept  warm, 
and  hand-fed.  At  this  stage  Mr.  Wilson  saw  it,  and  found  a 
pharyngeal  fissure  three  inches  in  length,  the  tongue  freely 
movable  and  working  in  harmony  with  the  normal  tongue. 

Broca,  "  Traite  des  Tumeurs,"  1869,  ii.  3G9. 

Dewar,  Journ.  of  Comj}.  FatU.,  xvi.  127. 

Goubaux,  Recueil  de  Med.  Vet.,  1854,  xxxi. 

Heusinger,  Deutsche  ZeUschr.f.  Thiermedicin,  1876,  ii. 

Magitot,  "Traite  d'Anomalies  de  Systeme  Dentaire,"  1877,  PI.  ix. 

Mettams,  Veterinarian,  Ixxii.  309. 

Roll,  ZeitsoTir.  d.   K.K.   Gesellscfiaft  der  Aerzte  in  Wien,  Marz,  1851,  Heft  3 

S.  xliii. 
Walley,  Journ.  of  Comp.  Path.,  ii.  152. 

For  the  cervical  teeth  of  sheep  see — 
Berger-Perriere,  Recueil  de  Med.  Vet.,  xii.  586. 
Giirlt,  "  Tliierische  Missgeburten,"  Berlin,  1877,  Taf.  xv. 
Wilson,  W.  T.,  Private  Letter. 


GROUP  Vn.    CYSTS 

CHAPTER  LV 

RETENTION-CYSTS 

Cysts,  or  cystomas,  result  from  the  abnormal  dilatation  of 
pre-existing  tubules  or  cavities.  In  the  simplest  form  they 
consist  of  a  wall  usually  composed  of  fibrous  tissue,  but  it 
not  infrequently  contains  muscle-fibre.  The  cyst-contents 
may  be  mucus,  bile,  saliva,  urine,  etc.,  according  to  the  nature 
of  the  organ  with  which  the  cyst  is  associated. 
Cysts  may  be  arranged  in  three  groups,  thus: 

1.  Retention-cysts. 

2.  Tubulo-cysts. 

3.  Hydroceles. 

There  are  some  conditions  often  classed  as  cysts  which  in 
this   work  will  be  arranged  as  a  sub-group  under  the  title 
Pseudo-Cysts,  and  will  embrace — 
i.  Diverticula, 
ii.  Bursse. 
iii.  Neural  cysts. 

In  this  and  the  next  chapter  Ave  shall  deal  with  reten- 
tion-cysts. 

When  the  duct  of  a  gland  becomes  obstructed,  the  fluid, 
hindered  from  escaping,  accumulates  in  the  ducts  and  acini 
and  dilates  them.  If  the  hindrance  to  the  free  flow  of  the 
secretion  is  maintained,  or  often  repeated,  the  glandular  tissue 
becomes  impaired,  then  atrophies,  and  finally  the  gland  and 
its  duct  become  converted  into  a  fluid-containing  sac  or  cyst. 

It  is  generally  believed  that  when  the  duct  of  a  gland 
is  completely  obstructed  the  conversion  of  the  parts  into  a 
cyst  is  a  passive  process ;  but  occasion  will  be  taken  in 
the  course  of  this  section  to  show  that  that  is  not  the 
case.  When  an  excretory  duct  is  so  completely  obstructed 
that   no  secretion  escapes,  then  the  gland  rapidly  atrophies. 

563 


564  GY8T8 

Retention-cysts  are  caused  by  obstruction  to  the  free  flow 
of  secretion,  or  temporary  arrests  of  the  flow  frequently 
recurring.  The  best  examples  of  cysts  arising  in  this  way  are 
those  due  to  dilatation  of  the  pelvis  and  infundibula  of  the 
kidney — a  condition  known  by  the  terra  hydronephrosis. 

The  purest  forms  of  retention-cysts  arise  in  connexion 
with  hollow  organs,  the  inner  walls  of  which  are  provided 
with  glands.  The  vermiform  appendix  is  a  case  in  point. 
This  tubular  structure  is  richly  provided  with  glands. 
Occasionally  the  communication  of  the  appendix  with  the 
csecum  is  obstructed,  and,  the  glands  continuing  to  secrete, 
the  accumulating  fluid  distends  the  appendix  into  a  sausage- 
shaped  cyst. 

The  uterus  is  another  example.  After  a  difficult  labour 
the  walls  .of  the  cervical  canal  are  not  infrequently  damaged, 
and  in  the  process  of  repair  the  canal  may  become  obstructed. 
This  leads  to  retention  of  the  products  secreted  by  the  uterine 
glands,  and  the  uterus  will  attain  such  proportions  as  to 
cause  the  enlargement  to  be  attributed  to  pregnancy;  the 
condition  is  known  as  hydrometra.  It  is  occasionally  seen 
in  old  women,  but  more  commonly  in  mammals  noimally 
furnished  with  bicornate  uteri,  such  as  ewes,  cows,  mares, 
and  sows.     It  may  be  unilateral  or  bilateral. 

When  occurring  in  mammals  in  which  the  uterus 
has  long  cornua — e.g.  the  cat,  bitch,  hare — the  distended 
cornua  are  apt  to  be  confounded  with  Fallopian  tubes.  One 
or  both  cornua  of  a  human  bicornate  uterus  may  be 
affected. 

The  danger  of  retention  of  this  kind  is  due  not  so  much 
to  the  size  of  the  cyst  as  to  the  great  risk  that  ensues  when 
large  collections  of  retained  secretions  are  invaded  by  putre- 
factive organisms.  The  cysts  in  such  an  event  become  con- 
verted into  abscesses,  and  the  life  of  the  individual  is  greatly 
imperilled.  These  changes  in  retention-cysts  are  indicated 
by  special  names — as  pyometra,  pyonephrosis,  etc. 

Cysts  of  the  liver. — All  cysts,  in  the  pathologic  limita- 
tion of  the  term,  arise  in  pre-existing  epithelium-lined  spaces 
and  ducts :  even  ducts  and  canals  of  microscopic  proportions 
are  often  the  source  of  cysts  of  such  dimensions  that  they 
cause  so  much  inconvenience  and  distress  as  to  necessitate 


GYSTS  OF   THE  LIVER 


566 


surgical  treatment.     This  is  illustrated  by  the  liver,  an  organ 
thoroughly  permeated  by  minute  passages — the  bile-canals. 

Two  forms  of  cysts  are  found  in  the  liver,  arising  from  its 
canals  and  ducts — namely,  multiple  cysts  and  solitary  cysts. 


Fig.  300. — Liver  shown  in  section.  The  spaces  on  the  cut  surface  are  dilated 
bile-canals.  From  a  woman  46  years  of  age.  (Museicm  of  the  Royal  College  of 
Surgeons,  London.) 

1.  Multiple  cysts  of  the  liver. — This  variety  has  long  been 
recognized  by  pathologists  under  the  term  general  cystic 
disease  of  the  liver.  In  typical  examples  the  liver  is  converted 
into  a  huge    honeycomb-like  mass  (Fig.  300).     The  cavities 


566  CYSTS 

vary  greatly  in  size — some  are  as  small  as  grape- seed,  others 
may  exceed  a  ripe  cherry  in  size.  The  cysts  may  project 
on  the  surface  of  the  liver,  but  though  this  organ  may  be 
enormously  enlarged  and  Aveigh  thirty-five  pounds,  yet  its 
shape  is  preserved.  The  smaller  cysts  are  lined  with  epithe- 
lium. This  is  best  seen  in  specimens  with  the  cystic  change 
in  an  early  stage,  when  the  dilated  canals  look  like  sharp, 
definite  punctures  in  the  liver  substance.  As  the  cysts 
increase  in  size  and  number,  the  hepatic  tissue  is  encroached 
upon,  and  appears  as  narrow  bridges  between  large  tracts  of 
honeycomb,  but  by  degrees  these  become  broken  up  by 
absorption,  and  then  the  remnants  of  the  normal  hepatic 
tissue  are  seen  as  islands  on  the  cut  surface  of  the  liver. 

The  microscopic  characters  of  the  cysts  when  examined  in 
the  early  stages  prove  that  they  arise  in  the  bile-canals,  but 
no  investigator  has  succeeded  in  ascertaining  the  cause  of 
this  disease,  or  in  associating  it  with  obstruction  to  the  escape 
of  bile.  The  most  remarkable  circumstance  connected  with 
this  disease  of  the  liver  is  its  occasional  association  with 
general  cystic  disease  of  the  kidneys  {see  p.  590). 

This  general  cystic  disease  of  the  liver  is  productive  of  great 
enlargement  of  the  organ,  but  is  painless,  causes  no  jaundice, 
presents  no  diagnostic  features,  and  comes  invariably  as  a 
post-mortem  surprise. 

This  curious  disease  has  attracted  the  attention  of  several 
pathologists,  including  Virchow,  Kokitansky,  Bristowe,  Still, 
Shattock,  and  Rolleston.  Blackburn,  in  a  careful  and  critical 
paper,  has  reviewed  the  various  theories  relating  to  this 
disease  and  collected  the  literature. 

2.  Solitary  (non-]:)arasitic)  cyst  of  the  liver. — This  is  a 
rare  condition,  and  the  general  character  of  such  a  cyst  may 
be  inferred  from  the  specimen  represented  in  Fig.  301.  In 
nearly  all  the  recorded  cases  the  cysts  grow  from  the  free 
margin  of  the  liver  and  possess  thin  walls  which  are  trans- 
lucent and  have  no  communication  with  the  gall-bladder. 
The  peritoneal  investment  and  the  capsule  of  the  liver  are 
directly  continuous  with  the  cyst-wall.  On  microscopic  ex- 
amination of  a  large  solitary  cyst,  which  I  enucleated  from  the 
liver  of  a  woman  75  years  of  age,  the  cyst-wall  at  the  point 
where  it  joins   the  liver  exhibited   small  loculi   lined   with 


GY8T8  OF   THE  LIVER 


567 


epithelium  ;  ducts  could  also  be  detected  lined  with  cubic 
cells.  The  cyst-wall  consisted  of  fibrous  tissue,  and  its  inner 
surface  presented  spaces  covered  with  flattened  epithelium. 
In  some  parts  of  the  cyst- wall,  liver  substance  was  detected. 
In  such  cysts  the  fluid  may  be  straw-coloured  bile,  or  blood. 

The   solitary  cyst  of  the  liver  probably  arises  from  the 
dilatation  and  fusion  of  bile-ducts,  and,  althouo'h  it  is  difiicult 


BO^t 


Fig.  301. — Cyst  (non-parasitic)  growing  from  the  free  border  of  the  liver.  Obtained 
post-mortem  from  a  woman  38  years  of  age.  {Museum  of  the  Royal  College 
of  Surgeons.) 


to  explain  its  origin,  attention  may  be  drawn  to  the  following 
points.  The  recorded  examples  occurred  in  women.  It  is 
noteworthy  that  the  liver  of  many  women  presents  along  its 
free  border  a  variable  strip  of  thin  atrophied  tissue,  which 
appears  almost  white  in  contrast  with  the  dark  hue  of  the 
normal  liver.  This  atrophy  of  the  free  border  of  the  liver  is 
attributed,  and  I  think  correctly,  to  the  pressure  of  stays  ; 
whether  this  be  true  or  not,  it  was  in  this  pale,  thin  strip  of 


568 


CYSTS 


liver  that  the  sohtary  non-parasitic  cyst  arose  in  my  patient, 
and  it  was  due  to  the  dilatation  of  the  bile-ducts  in  this  tissue  ; 
the  dilated  ducts  subsequently  fused  to  form  larger  spaces, 
much  in  the  same  way  that  cystic  spaces  arise  in  a  cavernous 
nsevus  from  the  fusion  of  adjacent  blood-vessels  composing 
the  primary  nsevus. 

Few   special   treatises   mention   the   solitary  cyst  of  the 


Fig.  302. — Gall-bladder  distended  -with  mucus  secondary  to  obsti-uction  of  the  cystic 
duct  with  gall-stones.  The  triangular  piece  of  liver  attached  to  it  was  removed 
with  the  gall-bladder. 

liver,  but  a  sufficient  number  of  examples  have  been  recorded 
to  prove  that  it  is  a  clinical  entity  and  may  require  surgical 
treatment.  In  a  patient  under  my  care  the  cyst  contained 
two  pints  of  straw-coloured  fluid  and  simulated  a  mesenteric 
cyst.  One  physician  who  saw  the  patient  regarded  the 
swelling  as  an  ovarian  cyst. 

In  regard  to  treatment,  two  methods  have  been  adopted. 
The  common  plan  consists  in  ojiening  the  cyst,  evacuating 


GALL-BLADDEB  569 

its  contents,  and  then  draining  it.  This  is  tedious :  in  my 
case  I  succeeded  in  enucleating  the  cyst- wall,  with  the  best 
consequences. 

It  is  worth  notice  that  multiple  cysts  of  the  liver  admit 
of  no  treatment,  and,  as  far  as  I  know,  do  not  admit  of 
diagnosis ;  the  solitary  (non-parasitic)  cyst  is  a  clinical  puzzle, 
but  is  amenable  to  surgery. 

The  gall-bladder. — This  structure  illustrates  very  well 
the  mode  of  formation  of  retention-cysts.  The  gall-bladder 
consists  of  three  coats,  of  which  the  middle  one  contains  un- 
striped  muscle-fibre  ;  the  inner  one  is  mucous  membrane  beset 
with  mucous  glands,  its  epithelium  being  directly  continuous 
with  that  lining  the  hepatic  ducts  on  the  one  hand  and  with 
the  epithelium  covering  the  duodenum  on  the  other.  The 
outer  coat  is  derived  from  the  peritoneum  and  subserous 
tissue.  Bile  from  the  hepatic  ducts  is  conveyed  into  the  gall- 
bladder by  way  of  the  cystic  duct,  and  when  it  escapes  from 
the  gall-bladder  it  again  traverses  the  cystic  duct  and  passes 
along  the  common  bile-duct  to  the  duodenum.  The  common 
duct  just  as  it  enters  the  wall  of  the  intestine  receives  the 
duct  of  the  pancreas.  The  point  of  junction  is  indicated  by  a 
slight  recess  known  as  the  ampulla  or  diverticulum  of  Yater. 
The  peculiar  arrangement  of  the  ducts  leading  to  and  from 
the  gall-bladder  renders  it  specially  liable  to  have  its  com- 
munications interfered  with.  Obstruction  may  occur  in  the 
cystic  duct  (Fig.  302),  in  the  common  duct,  in  the  ampulla, 
or  in  the  wall  of  the  duodenum.  The  obstruction  may  be 
due  to  impacted  gall-stones,  a  pancreatic  concretion  in  the 
diverticulum,  tumours  of  the  pancreas,  duodenum,  primary 
cancer  of  the  common  bile-duct,  etc. 

When  the  common  duct  is  obstructed  by  gall-stones,  the 
gall-bladder  usually  atrophies  in  consequence  of  cholecystitis. 
In  obstruction  due  to  cancer  of  the  head  of  the  pancreas  the 
gall-bladder  becomes,  as  a  rule,  greatly  distended  with  bile, 
When  the  cystic  duct  is  obstructed,  and  no  bile  finds  its  way 
into  the  gall-bladder,  the  latter  may  become  so  distended 
with  mucoid  fluid  and  attain  such  large  proportions  as  to 
be  mistaken  for  an  ovarian  cyst.  A  gall-bladder  distended 
in  this  way  is  really  a  viucocele,  and  the  consistence  of  the 
mucus  varies  greatly. 


570  CYSTS 

Ranula. — This  term  is  probably  one  of  the  oldest  in 
surgery,  and  its  etymology  is  not  very  obvious.  Until 
recentl}^  it  was  applied  to  all  cysts  in  the  floor  of  the  mouth, 
and  as  cysts  in  this  situation  are  of  various  kinds  and  arise 
from  different  structures,  it  naturally  followed  that  the  term 
gradually  came  to  possess  a  merely  topographical  signifi- 
cance. There  is  at  the  present  time  a  strong  tendency  to 
restrict  the  name  ranula  to  cysts  arising  in  connexion  with 
the  ducts  of  the  three  sets  of  salivary  glands  opening  into 
the  mouth,  and  to  designate  them  as  submaxillary,  sublingual, 
or  parotid  ranulse,  according  to  the  gland  affected.  If  sur- 
ofeons  w^ould  use  the  term  in  this  definite  sense  much  un- 
necessary  discussion  would  be  saved.  Ranulse  are  common 
in  connexion  with  the  submaxillary  and  sublingual  glands. 
The  cysts  are,  as  a  rule,  thin- walled,  and  lie  in  the  furrow 
between  the  gum  and  the  tongue,  and  bulge  upwards  into  the 
floor  o±  the  mouth.  When  large  they  cause  a  prominence 
in  the  submaxillary  triangle.  The  cyst  may  be  filled  with 
saliva.  Sometimes  it  contains  mucus  and  a  yellow  substance 
resembling  the  yolk  of  an  egg. 

Occasionally  the  obstruction  is  caused  by  a  calculus 
impacted  in  the  orifice  of  the  duct,  but  cases  come  under 
observation  in  which  the  duct  is  not  completely  obstructed, 
yet  the  fluid  is  retained.  Observation  teaches  that  w^hen  the 
main  excretory  duct  of  the  submaxillary  gland  is  blocked 
by  a  calculus,  inflammatory  (infective)  changes  follow  in  the 
gland,  which  subsequently  produce  hardening  (sclerosis)  of 
its  tissue.  Cystic  changes  are  exceptional,  and  there  is,  in 
all  probability,  a  pathological  cause  apart  from  mere  obstruc- 
tion concerned  in  their  production. 

Parotid  ranulse  are  rare  in  the  human  subject,  but  they 
have  been  observed  in  calves,  oxen,  and  horses. 

Much  needless  discussion  has  taken  place  in  regard  to  the 
sources  of  ranulse,  because  the  various  writers  seem  to  forget 
that  in  addition  to  sahvary  glands  there  are  mucous  glands, 
and  one  of  variable  size,  near  the  tip  of  the  tongue,  known  as 
Nuhn's  gland.  Any  of  these  may  dilate  into  a  cyst.  Still 
further  to  complicate  the  diagnosis,  dermoid  cysts  not  infre- 
quently arise  in  the  floor  of  the  mouth,  near  the  frsenum  ol 
the  tongue,  or  deeply  in  its  substance.    It  has  also  been  urged, 


PANGREATIG  GYSTS  571 

as  an  objection  to  the  view  that  ranulse  arise  in  the  ducts  of 
the  salivary  glands,  that  the  fluid  they  contain  is  not  always 
saliva.  This  is  very  weak  argument.  Many  hydronephrotic 
cysts  contain  fluid  which  it  would  be  difficult  to  regard  as 
urine,  and  an  obstructed  gall-bladder  is  sometimes  filled  with 
fluid  that  does  not  possess  a  single  attribute  of  bile.  So  a 
cyst  arising  in  connexion  with  a  salivary  gland  will  sometimes 
contain  fluid  that  fails  to  furnish  the  characteristic  reactions 
of  saliva. 

Pancreatic  cysts. — It  has  long  been  known  that  the 
duct  of  the  pancreas  is  liable  to  become  dilated,  and  as 
the  condition  is  analogous  to  the  distension  of  the  ducts 
of  the  buccal  salivary  glands,  dilatation  of  the  pancreatic 
duct  (canal  of  Wirsung)  is  sometimes  referred  to  as  a  "  pan- 
creatic ranula." 

Virchow  recognized  two  varieties  of  pancreatic  ranula. 
In  one  variety  the  canal  is  dilated  irregularly  throughout  its 
whole  extent,  so  that  it  assumes  the  appearance  of  a  chaplet 
of  cysts ;  in  the  other  the  duct  is  dilated  immediately  behind 
its  terminal  orifice.  Such  cysts,  he  writes,  may  attain  the 
size  of  a  fist,  and  are  consecutive  to  cicatricial  contractions 
and  compression  by  tumours.  The  cysts  are  not  filled  simply 
with  pancreatic  secretion,  for  when  they  attain  a  certain  size 
they  will  be  found  to  contain  mucoid  material,  products  of 
haemorrhages,  and,  not  rarely,  calculi.  Judging  from  what  is 
known  of  retention-cysts  in  general,  it  would,  as  a  matter  of 
simple  inference,  be  thought  that  pancreatic  ranulte  arise 
from  partial  obstruction  to  the  pancreatic  duct,  either  from 
impaction  of  a  pancreatic  calculus  in  the  terminal  segment 
of  the  duct,  a  gall-stone  lodged  at  the  duodenal  orifice,  or  a 
tumour  arising  in  connexion  with  the  ducts  or  tissues  in  the 
immediate  neighbourhood.  This,  however,  does  not  appear 
to  be  the  case,  for  pancreatic  cysts  have  been  observed  and 
no  obstruction  has  been  detected.  Besides  this,  the  duct  of 
the  pancreas  has  been  found  completely  obstructed  by  a 
■calculus,  and  the  gland,  instead  of  being  converted  into  a 
cyst,  has  atrophied,  its  secreting  elements  being  largely 
replaced  by  fibrous  tissue. 

Experimental  evidence  also  supports  this  conclusion,  for 
it  has  been  demonstrated  that  when  the  pancreatic  duct  is 


572  CYSTS 

occluded  during  life  by  a  ligature,  tlie  gland  does  not  become 
cystic,  but  atrophies.  Thus  experimenfal  and  clinical  evi- 
dence indicates  that  pancreatic  cysts  are  the  result  of  patho- 
logical changes  which  may,  or  may  not,  be  associated  with 
obstruction  of  the  duct. 

A  great  deal  of  attention  has,  during  the  past  ten  years, 
been  devoted  to  pancreatic  cysts  in  their  clinical  as  well  as 
their  pathological  aspect,  and  certainly  the  evidence  indicates 
that  other  causes  than  obstruction,  partial  or  complete,  are 
responsible  for  their  production. 

Cysts  described  as  pancreatic  sometimes  attain  very  large 
proportions,  and  examples  have  been  reported  with  a  capacity 
of  two  gallons  or  more.  These  very  big  cysts  form  smooth 
globular  swellings  in  the  upper  part  of  the  belly.  They  lie 
behind  the  peritoneum,  and,  of  course,  have  the  stomach  and 
transverse  colon  in  front ;  when  very  large  these  cysts  will 
extend  some  distance  below  the  transverse  colon. 

The  fluid  contained  in  large  pancreatic  cysts  is  usually 
turbid.  Sometimes  it  is  white  or  even  opalescent,  occa- 
sionally it  is  clear,  and  in  some  cysts  it  will  have  a  brown  or 
even  a  green  tint.  The  specific  gravity  varies  between  1010 
and  1020,  and  there  is  a  small  trace  of  albumin.  Mucin  is 
often  present,  also  tyrosin  and  blood-pigment,  and  traces  of 
urea  have  been  detected.  The  fluid  is  sometimes  capable  of 
emulsifying  fats. 

The  modes  by  which  very  large  pancreatic  cysts  arise  are 
not  by  any  means  clear,  but  it  is  important  to  bear  in  mind 
that  there  is,  in  a  very  significant  proportion  of  cases,  a 
definite  histor}^  of  antecedent  injury.  This  fact  gives  colour 
to  the  suggestion  that  some  of  the  cysts  are  due  primarily  to 
laceration  of  the  pancreas  and  subsequent  extravasation  of  its 
secretion  behind  the  peritoneum.  Another  very  important 
feature  of  these  cysts  is  the  liability  to  haemorrhage,  and  this 
may  take  place  so  abundantly  into  the  cyst  as  to  jeopardize 
the  life  of  the  patient;  indeed,  in  some  cases  it  has  been  fatal. 

Pancreatic  cysts  occur  at  almost  all  periods  of  life.  Ex- 
amples have  been  reported  as  early  as  the  eighth  year  of  life 
and  as  late  as  the  seventy- third.  They  appear  to  be  more 
frequent  in  men  than  in  women. 

Pancreatic   cysts   attributed    to   injury   have   followed   a 


DAGUYOPS  578 

variety  of  accidents,  siich  as  a  fall  from  a  great  height,  caus- 
ing abdominal  pain ;  a  crush  of  the  abdomen  between  the 
buffers  of  railway  waggons  ;  falls  from  a  horse,  or  from  a 
vehicle  ;  kicks  from  men,  and  in  several  cases  from  horses. 

'  Jordan  Lloyd  has  attempted  to  show  that  the  large  pan- 
creatic cysts  that  follow  injury  to  the  abdomen  are  really 
collections  of  fluid  in  the  cavity  of  the  lesser  omentum,  and 
when  the  fluid  has  the  property  of  rapidly  converting  starch 
into  sugar  it  may  be  assumed  that  the  pancreas  has  been 
injured.  He  also  points  out  that  the  characteristic  feature 
of  so-called  pancreatic  cysts — viz.  a  swelling  occupying  the 
epigastric,  umbilical,  and  left  hypochondriac  regions — is  pre- 
cisely that  which  would  result  from  distension  of  the  lesser 
bag  of  the  peritoneum.  It  is  probable  that  some  cases  of 
supposed  pancreatic  cysts  were  really  effusions  into  the  lesser 
bag  of  the  peritoneum,  for  undoubted  examples  of  distension 
of  this  cavity  with  fluid  have  been  observed,  dissected,  and 
described.  The  whole  subject  of  so-called  pancreatic  cysts 
has  been  ably  handled  and  the  literature  collected  by  Leith. 

Dacryops. — This  term  is  applied  to  cysts  occurring  in  the 
upper  eyelid ;  they  are  due  to  distension  of  the  ducts  of  the 
lachrymal  gland.  They  appear,  as  a  rule,  in  the  upper  and 
outer  part  of  the  eyelid,  the  cyst  extending  beneath  the 
border  of  the  orbit  towards  the  lachrymal  gland.  The  cyst 
enlarges  when  the  patient  weeps.  Dacryops  may  arise  in  two 
ways — either  as  a  consequence  of  a  wound  or  abscess  of  the 
lid,  or  as  a  congenital  defect.  As  a  rule,  they  are  of  traumatic 
origin.     The  condition  is  one  of  extreme  rarity. 

Hulke,  in  an  interesting  paper  on  this  subject,  states  his 
belief  that  these  cysts  were  first  accurately  described  by  Dr. 
J.  A.  Schmidt  in  1803,  and  that  Beer  (1817)  mentions  that 
he  had  six  cases  of  this  kind,  which  he  describes  under  the 
name  "  dacryops,"  previously  applied  to  them  by  Schmidt. 

When  these  cysts  are  opened  through  the  skin  a  fistula  is 
sure  to  be  the  result.  The  same  thing  often  happens  when 
the  cysts  have  a  traumatic  origin.  The  condition  is  then 
termed  dacryops  fistidosus. 

Cysts  of  the  hyaloid  canal. — This  tiny  relic,  which 
sometimes  persists  in  the  vitreous  after  the  disappearance 
of  the  central  hyaloid  artery,  may   occasionally  dilate    and 


574  OYSTS 

form  a  cyst  large  enough  to  be  visible  on  ophthalmoscopic 
examination. 

Blackburn,  "  Cystic   Disease  of  the  Liver  and  Kidney." — Trans.  Path.  Soc, 

vol.  Iv.  203  ;  with  a  complete  list  of  references. 
Bland-Sutton,  J.,  "  On  Solitary  (non-parasitic)  Cysts  of  the  Liver." — Brit.  Med- 

Journ.,  1905,  ii.  1167. 
Doran,  A.,  Med.-Chir.  Trans.,  1904,  Ixxxvii.  1,  with  literature. 
Hulke,  J.   W.,    "  Dacryops  ;  Dacryops  Fistulosus  Palpebrse  Superioris." — Boy. 

Lond.  OiMhal.  Hosp.  Rejrts.,  18.57-59,  i.  285. 
Leith,  R.  F.  C,  "  Euptnres  of  the  Pancreas  :  their  relations  to  pancreatic  cysts ; 

with  some  remarks  upon  treatment." — Edin.  Med.  Journ.,  1895,  xli.  423. 

Lloyd,  Jordan,  "Injury  to  the  Pancreas:  a  cause  of  effusions  into  the  lesser 

peritoneal  cavity." — Brit.  Med.  Journ.,  1892,  ii.  1051. 
Morton,  C.  A.,  Lancet,  1905,  ii.  1395. 
RoUeston,  H.  D.,  "  Diseases  of  the  Liver,"  1905. 
Sharkey,  S.  J.,  "  Simple  Cyst  in  connection  with  the  Liver." — Trans.  Path. 

Soc.,  1882,  xxxiii.  168. 
Sharkey,  S.  J.,   and  Glutton,  H.  H.,  "Case  of  Pancreatic  Cyst;   successful 

removal." — St.  Tliomas's  Hasp.  Repts.,  1893,  xxi.  271. 
Still,  G.  F.,  "  Congenital  Cystic  Liver  and  Cystic  Kidney." — Trans.  Path.  So  ., 

1898,  xlix.  155. 


CHAPTER    LVI 

RETENTION-CYSTS    (Concluded) 
H  Y  DUONEPHROSIS 

The  secretion  (urine)  of  the  kidneys  is  conclucted  into  the 
bladder  by  means  of  two  ducts  (the  ureters) ;  from  the  bladder 
the  urine  is  discharged  at  intervals  through  the  urethra. 
When  from  various  causes  the  urine  is  hindered  from  escaping 
freely,  either  from  the  bladder,  or  from  the  ureters  into  the 
bladder,  it  accumulates  in  the  ureters  and  dilates  them ;  the 
pressure  of  the  fluid  then  acts  upon  the  pelves  of  the  kidneys, 
and  if  maintained  causes  the  renal  pelves  to  be  dilated  into 
large  sacs,  converts  the  infundibula  into  large  tubes,  and 
finally  induces  atrophy  of  the  renal  tissue  until  the  kidneys 
are  converted  into  multilocular  sacs.  To  a  kidney  altered  in 
this  way  the  term  hydronephrosis  (Rayer,  1839)  is  applied. 
Hydronephrosis  arises  from  a  variety  of  causes,  and  the 
condition  of  the  ureter  associated  with  it  depends  on  the 
cause  and  situation  of  the  obstruction.  It  is  also  important 
to  bear  in  mind  that  the  largest  examples  of  hydronephrosis 
are  produced  by  partial  obstruction  to  the  flow  of  urine  or  by 
frequently  recurring  attacks  of  complete  obstruction.  It  is 
also  a  curious  fact  that  in  many  of  the  largest  examples  of 
hydronephrosis  it  is  difficult  to  demonstrate  the  cause. 

Hydronephrosis  may  be  bilateral  or  unilateral.  When  the 
obstruction  is  at  the  neck  of  the  bladder  or  in  the  urethra  it 
will  be  bilateral. 

The  chief  causes  of  bilateral  hydronephrosis  are — 

Calculus  in  the  urethra  or  in  the  bladder  (Fig.  303). 

Stricture  of  the  urethra. 

Tumours  of  the  prostate  gland ;  especially  an  enlarged 
middle  lobe. 

Tumours   and   cysts  of  the   pelvic   organs ;    especially 
impacted  uterine  and  cervix  fibroids. 

575 


576 


CYSTS 


In  bilateral  hydroneplirosis  secondary  to  obstruction  at  the 
neck  of  the  bladder,  an  interesting  change  may  sometimes  be 
observed  at  the  vesical  orifices  of  the  ureters.  Normall}^  these 
openings  scarcely  admit  a  fine  probe,  but  under  the  conditions 


Fig.  303. — Hydronepkrosis  secondary  to  a  large  calculus  in  the  bladder ;  two 
fragments  of  calculus  occupy  the  prostatic  portion  of  the  urethra.  The  left 
kidney  was  in  a  similar  condition.  The  patient,  a  man  26  years  of  age,  died 
with  complete  suppression  of  urine.    {Jfiiseion,  Middlesex  Hospital.')  (j  ncd.  size. ) 

just  mentioned  they  will  assume  a  circular  form,  and  be  large 
enough  to  admit  the  tip  of  the  little  finger,  so  that  fluid 
injected  into  the  bladder  through  the  urethra  will  enter  the 
ureters   and   gain  the  dilated  pelves  of  the  kidneys.      This 


HYDBONEPHBOSIS 


577 


condition  is  particularly  apt  to  supervene  upon  oft-repeated 
attacks  of  retention  of  urine  secondary  to  pressure  on  the 
urethra  exercised  by  a  uterus  occupied  by  fibroids,  especially 


Fig.  304. — The  urinary  organs  with  the  right  adrenal  of  a  new -torn  child. 

those    which    grow    in    the    cervix    and   become    impacted 
immediately  before  the  incidence  of  a  menstrual  period. 

Antenatal  hydronephrosis. — A  very  large  number  of  ex- 
amples of  hydronephrosis  have  been  carefully  examined  and 
recorded  in  children  at  birth,  and  in  some  of  the  specimens  the 
distension  of  the  pelves  of  the  kidneys  has  been  so  great  as  to 
2l 


578  CYSTS 

obstruct  delivery  and  entail  embryotomy  in  order  to  allow  of 
the  extraction  of  the  foetus. 

In  many  of  the  records  the  reporters  state  that  they  were 
unable  to  find  anj'thing  to  explain  the  condition ;  in  some  of 
the  more  recent  cases,  however,  the  cause  of  the  obstruction 
has  been  determined.     The  chief  of  these  causes  are : — ■ 
Imperforate  urethra  (Figs.  314,  31G). 
Imperforate  hymen  (Fig.  317). 
Torsion  of  the  penis  (Fig.  305). 

Antenatal  hydronephrosis  is  a  subject  of  great  interest, 
because  it  serves  to  show  that  the  kidneys  are  functional  in 
the  late  stages  of  fcetal  life,  and  supports  the  view  that  the 
bath  of  amnionic  fluid  (or  hydrosphere)  in  which  the  foetus 
floats  represents,  at  any  rate  in  part,  foetal  urine.  It  also 
throws  some  light  on  cases  of  advanced  hydronephrosis  some- 
times met  with  in  infants  and  young  children,  and  for  which 
no  adequate  cause  had  previously  been  forthcoming. 

The  urinary  organs  represented  in  Fig.  304  were  obtained 
from  an  infant  which  survived  its  birth  a  few  days.  The 
right  kidney  only  was  present ;  it  occupied  its  normal  position 
in  the  loin.  Its  infundibula,  pelvis,  and  ureter  were  widely 
dilated,  and  at  the  point  where  the  ureter  opened  into  the 
bladder  there  was  a  small  circular  diaphragm-like  valve,  but 
this  structure  offered  no  obstruction  to  the  flow  of  fluid  from 
the  ureter  into  the  bladder  when  tested  after  death. 

The  bladder  presented  only  one  ureteral  orifice,  and  its 
walls  were  thinner  than  usual.  The  penis,  urethra,  and  tes- 
ticles were  normal,  and  the  left  adrenal  occupied  its  usual 
position.  No  traces  of  the  left  renal  artery,  vein,  or  ureter 
were  found.     The  anus  was  normal. 

In  this  case  dissection  failed  to  bring  to  light  anything  to 
account  for  the  distension  of  the  excretory  ducts  of  the 
kidney,  but  it  clearly  indicated  that  mechanical  obstruction 
of  some  kind  interfered  with  the  flow  of  urine  through  the 
vesical  orifice  of  the  ureter. 

Torsion  of  the  penis. — It  is  an  undoubted  fact  that 
torsion  of  the  penis  and  bilateral  hydronephrosis  are  some- 
times associated,  and  it  is  possible  that  in  some  cases  of 
congenital  double  hydronephrosis  in  which  there  was  great 
dilatation  of  the  ureters  and  in  which  careful  dissection  of 


H  YDR  ONE  PER  OS  IS 


579 


the  parts  failed  to  detect  any  organic  cause,  twisting  of  the 
penis  may  have  been  overlooked. 

A  baby  three  months  old  had  his  penis  directed  laterally  ; 
the  organ  was  brought  into  a  natural  position,  but  on  being 
released  it  at  once  resumed  its  abnormal  deflection  to  the 
left  (Fig.  305).  This  penis,  as  is  the  case  with  twisted  penes 
in  general,  was  unusually  large.  There  was  also  a  groove 
on  the  under-surface  of  the  glans  indicating  a  minimum 
degree  of  hypospadias;  the  frtenum  was  absent.  At  the 
angle  of  torsion  there  was  a  sac-like  pouch  of  skin.  The 
penis   was   probably  distorted   in   this  way  by  the  pressure 


Fig.  30,5.— Twisted  peuis.     The  small  figure   shows  the  groove  on  the  glans   and 
the  absence  of  the  frsenum.     {Xat.  size.) 

of  the  thighs  whilst  in  the  uterus.  It  is  possible  that  the 
penis  may  be  nipped  between  the  thighs  and  may  obstruct 
the  urethra  and  lead  to  hydronephrosis  without  its  being 
actually  twisted. 

Unilateral  hydronephrosis  has  many  causes: — 
Retention  of  a  calculus  in  the  ureter. 
Tumour  of  the  bladder  implicating  the  vesical  orifice 

of  the  ureter. 
Calculus  lodged  in  the  pelvis  of  the  kidney  and  block- 
ing the  orifice  of  the  ureter  (Fig.  311). 
Partial  rotation  of  the  kidney  kinking  the  ureter. 
Tumours  and   cysts  of  the   pelvic  organs  pressing  on 
the  ureter. 


580 


CF^ST^S' 


Cicatrix  of  the  ureter  due  to  injury. 

Inadequacy  of  the  ureter  (Fig.  309). 
It  has  been  suggested  that  the  ureter  is  occasionally  ob- 
structed by  branches  of  the  renal  artery  taking  an  abnormal 
course.     I  have  made  a  careful  study  of  cases   supposed   to 


rig.  306. — Kidney  iii  the  conditiou  known  as  hj'di'oueplu'osis,  showing  the  way  in 
which  the  renal  vessels  are  stretched  across  the  sac  and  interfere  with  the  ureter. 


demonstrate  this,  and  have  been  convinced  that  the  unusual 
relation  of  the  vessels  is  often  due  to  the  dilatation  of  the 
renal  pelvis,  and  that  the  constricting  effects  supposed  to  be 
exercised  by  the  artery  are  the  direct  outcome  of  the  increase 
in  the  size  of  the  pelvis  (Fig.  306). 

Among  uncommon  varieties  of  unilateral  hydronephrosis 
may  be  mentioned  sacculation  of  one  half  of  a  horseshoe 


HYDRONEPHEOS'IS  581 

kidney,  and  the  rarer  anomaly  in  which  a  kidney  is  furnished 
with  two  ureters,  one  of  which  becomes  obstructed  and  leads 
to  dilatation,  of  that  portion  of  the  renal  pelvis  connected  with 
it,  and  corresponding  atrophy  of  that  part  of  the  renal  cortex 
which  drains  into  it. 

Intermitting  hydronephrosis. — When  a  hydronephrotic 
kidney  is  of  large  size  it  can  be  perceived  clinically  as  a 
definite  tumour.  It  occasionally  happens  that  patients  come 
under  observation  with  a  swelling  in  the  loin  which  can  be 
readily  perceived  at  one  examination  but  not  at  another,  or 
it  obviously  diminishes  in  bulk  without  completely  vanishing. 
In  some  of  these  cases  the  patients  are  able  to  state  definitely 
that,  coincidently  with  the  diminution  in  the  volume  of  the 
tumour,  there  has  been  a  sudden  increase  in  the  quantity  of 
the  urine  voided.  The  urine  in  some  instances  has  been 
found  to  contain  traces  of  blood  and  mucus.  To  hydrone- 
phrosis of  this  kind  the  term  interrtiitting  is  applied. 

It  must  be  borne  in  mind  that  there  may  be  difficulty  in 
some  cases  in  deciding  clinically  between  a  very  large  hydro- 
nephrotic cyst  and  an  ovarian  or  parovarian  cyst,  and  it  is 
well  established  that  cysts  of  the  ovary  and  parovarium 
sometimes  rupture,  and  the  fluid,  escaping  into  the  perito- 
neum, is  absorbed,  and  rapidly  excreted  by  the  kidneys. 
Thus,  jjrofuse  diuresis  following  ui^on  the  sudden  disap- 
jjearance  of  an  abdominal  tumour  is  as  characteristic  of 
rupt^ure  of  an  ovarian  cyst  as  of  an  intermitting  renal  cyst. 

There  can  be  little  doubt  that  nearly  all  hydronephroses 
intermit,  but  the  term  intermitting  hydronephrosis  is  reserved 
for  those  examples  in  which  there  is  great  diminution,  and  in 
some  instances  temporary  disappearance,  of  the  swelling. 

Exceptionally,  both  kidneys  when  hydronephrotic  may 
intermit  alternately.  Of  this  rare  form  I  have  had  one  case 
under  my  care;  as  the  diagnosis  was  somewhat  obscure, 
cceliotomy  was  performed.  In  the  course  of  the  operation 
the  phenomenon  of  intermission  was  actually  observed.  The 
hydronephrosis  diminished  in  size,  and  the  bladder  slowly 
filled.  Intermitting  hydronephrosis  is  also  associated  with 
the  remarkable  anomaly  known  as  inadequate  ureter. 

It  is  a  startling  fact  that  many  of  the  largest  specimens 
of  hydronephrosis  are    those  in  which  no  obstruction  could 


582 


CYSTS 


be  demonstrated,  and  the  histories  of  the  patients  fail  to 
throw  any  hght  on  the  cause  (Fig.  307).  The  most  remark- 
able example  of  this  is  the  case  of  Mary  Nix,  who  died 
at  Hampton  Poyle,  near  Oxford,  at  the  age  of  23.  She 
had  a  hydronephrosis  containing  fluid  to  the  amount  of 
thirty  gallons,  wine  measure.  The  dissection  of  the  body  was 
conducted  by  Samuel  Glass  with  "some  learned  gentlemen  of 


Fig.  307. — Unilateral  (intermitting)  hydronephrosis  (without  obvious  cause).      The 
ureter,  at  the  point  where  it  left  the  renal  sinus,  had  a  diameter  of  8  cm. 


Nothing  was   found 


to    account    for   the 


the   university, 
condition. 

Now  that  we  know  many  cases  of  dilated  ureter  and 
sacculated  kidney  have  an  antenatal  cause,  it  is  very  prob- 
able that  many  large  hydronephroses  of  inexplicable 
origin  in  the  adult  began  while  the  individual  tenanted 
the  uterus. 

Inadequate  ureter, — It  is  well  recognized  that  the  junc- 
tion of  the  renal  pelvis  with  the  ureter  proper  is  indicated  by 


B  YDEONEPHBOSIS 


583 


a  marked  narrowing  of  the  lumen  of  the  duct,  which  may 
be  conveniently  called  the  "  ureteral  strait."  It  occasionally 
happens  that  the  ureter  from 
this  point  downwards  is  very 
markedly  narrow,  and  is  some- 
times even  less  than  one-fourth 
its  proper  dimensions  (Fig.  309). 

Abnormally  narrow  ureters 
of  this  kind  may  be  convenient- 
ly termed  "  inadequate."  Five 
examples  of  this  condition  have 
come  under  my  observation,  and 
in  each  instance  it  was  asso- 
ciated with  intermitting  hydro- 
nephrosis. It  is  an  extraordinary 
fact  in  some  of  these  cases  that 
the  urine  will  collect  and  form 
a  sac  holding  two,  three,  or 
even  four  litres,  and  produce 
very  great  pain  ;  suddenly,  and 
without  any  warning,  the 
blockade  will  be  raised,  and  the 
urine  will  pass  into  the  bladder 
and  be  voided,  and  the  laro-e 
cystic  swelling  subside  in  a 
night.  This  excessive  narrow- 
ness of  the  ureter  is  most  prob- 
ably a  congenital  defect. 

The  insidious  way  in  Avhich 
the  gradual  dilatation  of  the 
renal  pelvis,  infundibula,  and 
calyces  destroys  a  kidney  is  very 
extraordinary.  When  hydro- 
nephrosis is  unilateral  it  rarely 
betrays  itself  until  the  tumoiu' 
is  very  large ;  often  the  only 
trouble  it  causes  is  increased 
frequency  of  micturition. 

When     the    hydronephrosis 

,  -1    ^        1    ,1  .  ^       „  Fig.  308.— Hydi'o-ureter  without  ob- 

IS    bilateral    the    signs    are     often  vious  cause.     From  an  old  mau. 


584 


CYSTS 


in  abeyance  until  tlie  amount  of  renal  capital  is  reduced  to 
the  minimum  amiount  capable  of  meeting  the  ordinary  de- 
mands of  the  individual ;  directly  there  is  an  extra  call,  then 
the  small  balance  of  available  renal  tissue  becomes  alarmingly 
manifest,  and  the  patient  dies. 

A  rare  combination  of  inadequate  ureter  and  sacculated 


Fig.  309.— Dilated  renal  pelvis  associated  with  an  inadequate  ureter. 


kidney  is  to  find  a  sacculus  stuffed  with  a  multitude  of  small 
calculi.  The  kidney  in  Fig.  310  is  of  this  character.  I  removed 
it  from  a  man  in  the  Middlesex  Hospital  in  1904.  The 
calculi  are  in  the  museum  of  the  Royal  College  of  Surgeons, 
which  contains  a  similar  specimen,  not  only  as  regards  the 
large  number  of  calculi  and  their  shape,  but  also  in  the  fact 
that  the  kidney  which  contained  them  was  "  hydronephrotic 
and  the  ureter  narrowed."  The  specimen  was  obtained  after 
death  from  a  man  aged  19  years. 


PYONEPHROSIS  585 

Pyonephrosis. — Although  a  hydronephrosis  continues  its 
course  in  secret,  it  is  ahiiost  certain  to  be  made  manifest 
when  it  suppurates,  and  my  observations  among  the  quick 
and  the  dead  have  taught  me  that  this  is  one  of  the  greatest 
dangers  to  which  an  individual  with  unilateral  hydronephrosis 
is  liable  (Fig.  311). 


Fig.  310. — Sacculated  kidney  with  au  inadequate  ua-eter ;  the  largest  sacculus  con- 
tained more  than  40,000  calculi,  which  were  iridescent  and  resembled  little 
balls  of  burnished  gold.     Removed  from  a  man  38  years  of  age. 

It  is  necessary  to  draw  a  distinction  between  pyone- 
phrosis and  suppurating  hydronephrosis.  In  the  case  of  a 
pyonephrosis  the  lesion  is  inflammatory  from  the  outset, 
whether  it  starts  primarily  in  the  kidney  or  spreads  to  this 
gland  from  the  bladder,  ureter,  or  elsewhere. 

In  some  cases  of  suppurating  hydronephrosis  under  my 
own  care,  I  have  been  satisfied  that  the  colon  was  the  source 


586 


CYSTS 


of  infection,  and  the  pus  contained  Bacillus  coli  coinmunis. 
The  intimate  relations  existing  between  the  kidney  and  colon, 
more  especially  when  the  former  is  hydronephrotic,  make  one 
wonder  that  fistulous  communication  between  these  viscera 
is  not  a  frequent  complication. 

Congenital  cystic  kidney.— This  term  is  applied  to  a  very 


Fig.  311. — Pyonephrosis  in   section;    the  pelvis  at  its  junction  with  the  ureter  is 
partially  blocked  by  a  calculus.     {Miiseii/ji  of  the  Ro>jaI  College  of  Surgeons.) 

characteristic  disease  of  the  kidneys.  In  tj^pical  examples 
these  organs  are  converted  into  cystic  masses,  so  that  they 
exhibit  a  sponge-like  appearance  on  section.  The  cysts  vary 
greatly  in  size ;  some  are  as  small  as  rape-seeds,  others  as 
large  as  cherries  ;  they  rarely  exceed  these  dimensions.  Some 
of  the  cysts  project  from  the  surface  of  the  kidney,  but,  though 
interfering  with  the  smoothness  of  the  gland,  they  do  not 
distort   it.       The   cortical   and   medullary   portions  of  such 


CONGENITAL   CYSTIC  KIDNEY 


587 


kidneys  are  indistinguishably  blended,  but  here  and  there 
tracts  of  cortical  tissue  may  be  detected  among  the  cysts  (Fig. 
312).  In  the  early  stages  the  cyst-walls  have  a  membrana 
propria,  and  are  lined  with  tesselated  epithelium.  In  ad- 
vanced stages  of  the  disease  and  in  the  large  cysts  the  epi- 
thelium disappears.  A  striking  feature  of  these  kidneys  is 
the  narrowness  of  the  ureters,  and  yet  in  all  the  cases  which 
have  come   under  my   observation   these   ducts    have  been 


Fig.  312. — Cougeiiital  cystic  kidney  in  section.     {Xat.  size.) 
{Museum  of  the  Hoijal  College  of  Surgeons.') 

pervious  throughout.    The  arteries  supplying  kidneys  changed 
in  this  way  are  smaller  than  normal. 

A  congenitally  cystic  kidney  sometimes  attains  an 
enormous  size,  so  large  indeed  as  seriously  to  impede  labour, 
and  in  many  cases  embryotomy  has  been  necessary  in  order 
to  enable  delivery  to  be  effected.  In  a  large  proportion  of 
instances  in  which  the  foetus  comes  away  without  difficulty 
it  is  still-born  and  often  malformed;  such  conditions  as 
anencephalia,  club-foot,  and  spina  bifida  are  often  associated 


588 


GTSTS 


with  congenital  cystic  disease  of  tlie  kidneys.  Minor  degrees 
of  the  affection  are  not  incomjDatible  with  life,  and  several  in- 
stances are  known  in  vdiich  such  kidneys  have  been  found  in 
adult  individuals. 

Although  this  condition  of  kidney  is  very  common  and 
specimens  illustrating  it  exist  in  many  pathological  museums, 
Ave  know  very  little  concerning  the  early  stages.  I  have  ex- 
amined a  well-marked  example  in  a  foetus  of  the  sixth  month, 


Fig.  313. — Congenital  cystic  kidney  ;  early  stage.     {Shattock.) 

and  Shattock  observed  one  at  the  fourth  month.  The  earliest 
stage  has  been  observed  by  Shattock  (Fig.  318),  and  a  careful 
examination  of  the  minute  structure  of  the  cyst,  as  well  as  a 
comparison  of  the  histology  of  the  cyst  with  that  of  the  meso- 
nephros  (Wolffian  body),  induced  him  to  think  it  probable 
that  these  kidneys  consisted  of  a  combination  of  mesonephros 
and  metanephros.  Virchow  regarded  the  cj^sts  as  dilatations 
of  the  uriniefrous  tubules  in  consequence  of  the  absence  of  a 
renal  pelvis.  It  is,  however,  a  curious  fact  that  "  congenital 
cystic  kidney "  occasionally  occurs    in  association    with   im- 


CONGENITAL  CYSTIC  KIDNEY 


589 


perforate  urethra.  A  very  remarkable  case  came  under  my 
notice  in  which  a  child  born  at  full  term,  but  with  great 
difficulty  on  account  of  the  large  size  of  its  belly,  was  found 
to  have  an  imperforate  urethra,  a  large  dilated  left  ureter, 
and  a  hydronephrotic  left  kidney.  The  opposite  kidney  was 
a  typical  example  of  the  congenital  cystic  kidney  (Fig.  314). 


Adrenal. 


Bladder. 


Fig.  314. — Urinary  organs  of  a  foetus.  The  urethra  is  imperforate,  the  bladder  hyper- 
trophied,  the  left  ureter  dilated,  and  the  kidney  hydronephrotic.  The  right 
kidney  is  a  congeries  of  cysts  (congenital  cystic  kidney). 

This  combination  of  the  two  forms  of  hydronephrotic  and  con- 
genital cystic  kidney  in  the  same  individual,  associated  with 
imperforate  urethra,  supports  Yirchow's  view  that  the  cysts 
are  due  to  ectasia  of  uriniferous  tubules. 

The  large  number  of  specimens  of  congenital  cystic 
kidney  preserved  in  museums  indicates  that  the  condition, 
if  advanced  at  the  time  of  birth,  is  incompatible  with  life.     It 


590 


CYSTS 


is,  however,  quite  certain  tliat  a  precisely  similar  change  is 
met  with  in  adults,  and,  what  is  also  remarkable,  it  is  very 
frequently  associated  with  a  similar  change  in  the  liver 
(see  p.  566).  The  available  facts  indicate  that  a  moderate 
amount  of  cystic  change  in  the  kidneys  is  not  incompatible 
Avith  life,  but  as  the  disease  advances  the  secreting  tissue  of 
the  organs  is  slowly  but  surely  destroyed,  and  in  due  course 
uraemia  supervenes  and  the  patient  dies. 


Fig.  315. — Localized  cystic  disease  of  the  kidney.     {After  Edmunds.) 

There  is  reason  to  believe  that  this  cystic  change  may  be 
limited  to  part  of  a  kidne}^.  Edmunds  described  a  speci- 
men (Fig.  315)  which  he  removed  from  a  girl  of  18  years,  in 
which  "  an  encapsuled  tumour "  projected  into  one  of  the 
calyces  of  the  kidney.  It  had  a  diameter  of  6  cm.,  and  was 
composed  of  a  "  congeries  of  cysts  "  lined  with  cubical  epi- 
thelium. 

The   large   cyst  connected  Avith  the  side  of  the  bladder 


CONGENITAL   CYSTIC  KIDNEY 


591 


represented  in  Fig.  314  had  a  capacity  of  300  c.c. ;  it  is 
a  dilated  ureter.  Such  a  condition  is  often  mistaken  for  a 
bifid  bladder. 

Assuming  that  the  congenital  cystic  kidney  is  due  to 
pressure  leading  to  dilatation  of  the  uriniferous  tubules,  we 
are  met  by  a  difficulty  in  dealing  with  the  specimen,  Fig.  314  : 


Fig.  316. — Fcetus  of  the  fourth  mouth,  with  imperforate  urethra  and  a  large  dis- 
tended bladder.     The  kidneys  were  cystic,  as  in  Fig.  314.     (Shattock.) 

the  same  cause  has  produced  hydronephrosis  in  one  kidney 
and  general  cystic  disease  in  its  fellow.  I  think  the  difference 
may  be,  in  part  perhaps,  explained  by  the  period  of  intra- 
uterine life  at  which  the  obstruction  manifests  itself 

Shattock  described  a  foetus  of  the  fourth  month  with  an 
imperforate  urethra;    this   fcetus   had   a  very   large   dilated 


592 


GY8T8 


bladder  (Fig.  316),  and  both  kidneys  were  typical  examples 
of  general  cystic  disease. 

The  museum  of  St.  Bartholomew's  Hospital  contains  the 
reproductive  organs  of  a  child  born  at  full  time :  the  hymen 
was  imperforate  and  the  bladder  greatly  distended ;  the 
vagina  was  converted  into  a  large  cyst  containing  mucus 
(Fig.  317).  The  pressure  of  the  distended  vagina  had  com- 
pressed the  urethra,  causing  retention  of  urine  which  over- 
filled the  bladder,  and  dilated  the  renal  pelvis,  producing  the 
condition  known  as  sacculated  kidney.    A  comparison  of  these 


Fig.   317.— Kidney,  uterus,  vagina,   and  bladder  of  a  new-bom  child,  shown  in 
section.     The  distension  of  the  vagina  and  uterus  is  due  to  an  imperforate 
hjTnen.     The  ureter  is  widely  dilated  and  the  kidney  sacculated. 
{Museum  of  St.  Barthohmciv'' s  Sospifal.) 

specimens  seems  to  indicate  that  the  dilatation  of  the  urini- 
ferous  tubules  which  results  in  general  cystic  disease  of  the 
kidneys  is  due  to  some  cause  acting  very  early  in  embryonic 
life.     When   obstruction   to  the   outlet   of  urine   occurs   in 


CONGENITAL   GYSTIG  KIDNEY  593 

the  later  stages  of  intra-uterine  life,  dilatation  of  the  renal 
pelvis  and  its  recesses  (hydronephrosis)  is  the  more  frequent 
consequence. 

It  is,  however,  a  point  of  some  importance  to  realize  that 
there  are  cases  in  which  the  kidneys,  though  the  seat  of 
general  cystic  disease,  are  capable  of  performing  their  function, 
and  the  individuals  attain  adult  life.  In  such  cases  the  cysts 
of  the  kidneys  increase  in  size,  and  the  organs  attain  the  pro- 
portions of  full-grown  pumpkins.  Eventually  the  secreting 
substance  of  the  kidneys  is  destroyed  and  the  patient  slowly 
dies  from  ursemia.  It  is  important  to  realize  this  condition 
of  kidney,  because  in  several  instances  surgeons  have  re- 
moved organs  thus  enlarged :  such  interference  has  not  been 
to  the  advantage  of  the  patients.  The  museum  of  the  Royal 
Colleo'e  of  Surgeons,  London,  contains  an  excellent  series  of 
specimens  illustrating  general  cystic  disease  of  the  kidney  in 
man  and  other  mammals. 

Bland-Sutton,  J.,  "  A  Kidney  which  contained  more  than  40,000  Calculi." — 
Lancet,  1905,  i.  125. 

Edmunds,  W.,  "  Cystic  Adenoma  of  Kidney." — Trans.  Path.  Soc,  1892,  xliii.  89. 

Glass,  S.,  "An  Uncommon  Dropsy  from  the  want  of  a  Kidney;  and  descrip- 
tion of  a  large  Saccus  that  contained  the  Water,  sent  to  Dr.  Mead." — 
PJiil.  Trans.,  1747,  xliv.  337. 

Pye-Smith,  P.  H.,  "  Cystic  Disease  of  the  Liver  and  both  Kidneys." — Trans. 
Path.  Soc,  1881,  xxxii.  112. 

Shattock,  S.  G.,  "  Imperforate  Urethra  in  a  Foetus  of  about  the  fourth 
month." — Trans.  Path.  Soc,  1888,  xxxix.  185. 

Virchow,  R.,  "  Congenitale  Nierenwassersucht." — Gesamvite  Aihandl.  z,  wissen- 
schaft  MecUcin,  1856,  p.  839. 


2m 


CHAPTER  LVII 

TUBULO-CYSTS 

The  human  body  contains  certain  tubes  which,  so  far  as  is 
known,  serve  no  useful  purpose  in  the  adult,  and  may  be 
called  in  consequence  functionless  ducts.  Some  of  these — 
e.o-.  the  vitello-intestinal  duct  and  the  urachus — were  probably 
useful  to  the  embryo ;  others,  like  the  parovarium  and 
Gartner's  duct,  are  serviceable  in  the  male,  as  they  act  as 
conduits  to  the  testis.  Functionless  ducts  must  not  be  con- 
founded with  obsolete  canals :  these  serve  no  useful  purpose 
in  man,  but  were,  in  all  probability,  functional  in  the  ances- 
tors of  existing  vertebrates  (Chap.  xlvi.).  Both  sets  of 
canals  are  of  interest  to  the  pathologist,  as  they  are  the 
source  of  cysts  which  are  not  only  inconvenient  to  the 
individual  but  actually  dangerous  to  life. 

The  genus  tubulo-cysts  includes  the  seven  following 
species  :  (1)  Cysts  of  the  vitello-intestinal  duct ;  (2)  cysts  of 
the  urachus  ;  (3)  paroophoronic  cysts ;  (4}  parovarian  cysts 
(p.  514) ;  (5)  cystic  disease  (adenoma)  of  the  testis  (p.  539) ; 
(6)  cysts  of  Gartner's  duct  (p.  518) ;  (7)  cysts  of  Miiller's  duct. 

Cysts  of  the  vitello-intestinal  duct. — It  is  not  un- 
common to  find  connected  with  the  umbilicus  of  babes  and 
young  children  small  tumours  varying  in  size  from  a  pea  to 
a  cherry.  These  tumours  are  bright-red,  soft  and  velvety  to 
the  touch,  and  are,  as  a  rule,  connected  with  the  navel  by 
slender  pedicles,  and  in  appearance  resemble  red  currants; 
occasionally  they  are  sessile. 

These  tumours  are  composed  of  unstriped-muscle  fibre, 
mucous  membrane,  Lieberkubn's  follicles,  and  columnar  epi- 
thelium, collected  into  a  mass.  Typical  cases  have  been 
carefully  described  by  many  observers. 

In  rarer  cases  the  umbilicus  is  occupied  by  a  cyst,  which 
may  project  externally  or  internally.     Such  a  cyst  is  lined 

594 


GYSTS   OF   TEE    VITELLINE  DUCT 


595 


Lung  diverticulum. 


Stomach. 


with  mucous  membrane  furnished  with  villi,  columnar  epithe- 
lium, and  follicles.  A  cyst  of  this  character  is  easily  con- 
founded with  the  sac  of  an  umbilical  hernia. 

The  histology  and  position  of  pedunculated  tumours  and 
sessile  cysts  at  the  navel  indicate  the  structure  from  which 
they  arise — viz.  a  remnant  of  the  vitello-intestinal  duct  which, 
in  the  embryo,  traverses  this  part  of  the  abdominal  wall  (Fig. 
318).  In  transverse  sections  of  the  umbilical  cord,  close  to 
the  belly  wall  of  the  embryo  at  the  fifth  month,  the  vitello- 
intestinal  duct  can  often  be 
detected,  with  its  lumen  lined 
with  subcolumnar  epithelium. 
It  is  also  well  known  that 
the  duct,  instead  of  shrivel- 
ling, sometimes  grows  j^ari 
■passu  with  the  gut  with  which 
it  is  connected,  and  acquires 
a  lumen  almost  equal  to  that 
of  the  ileum.  Instead  of  per- 
sisting from  the  gut  to  the 
navel,  the  duct  may  atrophy, 
leaving  a  small  portion  at- 
tached to  the  intestine  or  to 
the  abdominal  wall.  Such 
remnants  may  develop  into 
cysts  the  walls  of  which  are 
identical  in  structure  with 
those  of  the  small  intestine. 

A  much  rarer  variety  of 
cvst  arising  in  a  remnant  of 
the  vitello-intestinal  duct  is  due  to  the  distension  of  that 
portion  of  the  duct  which  is  connected  with  the  ileum.  In 
recently  hatched  chicks  the  intestinal  attachment  of  the  duct  is 
often  indicated  by  a  nipple-like  process  on  the  free  border  of 
the  gut.  This  is  hollow,  but  does  not  communicate  with  the 
lumen  of  the  ileum.  As  a  rule  it  atrophies  completely.  It 
may,  however,  grow  and  form  a  large  cyst.  The  museum  of 
the  Royal  College  of  Surgeons  contains  a  piece  of  intestine 
from  an  emu  chick  with  a  large  cyst  suspended  from  it  by 
means  of  a  narrow  and  acutely  torsioned  pedicle.     This  cyst, 


Fis 


Vitello-intestinal 
duct. 


,  318.  — Diagram  of  the  alimentary 
canal  of  the  embryo,  showing  the 
position  of  the  yolk-sac. 


596 


TUBULO-CTSTS 


in  all  probability,  originated  in  a  persistent  portion  of  the 
vitello-intestinal  duct. 

Cysts  of  like  proportions  and  of  identical  origin  have 
been  recorded  in  the  human  subject.  One  of  the. best-known 
cases  was  reported  by  Roth. 

Occasionally  a  persistent  vitello-intestinal  duct  will  remain 
open  at  the  umbilicus  and  discharge  fseces.  •  Such  cases  have 
been  successfully  dealt  with  by  surgeons. 

Sherren  removed  a  Meckel's  diverticulum  (Fig.  319) 
from  a  man  ao'ed  38 :  it  contained 
concretions  composed  of  cholesterin, 
calcium  oxalate,  and  bile-pigment.  A 
valve  existed  at  the  junction  of  the 
diverticulum  with  the  ileum.  The 
operation  was  undertaken  for  acute 
colic. 

A  diverticulum  is  present  in  about 
2  per  cent,  of  the  population.  It  is  a 
very  troublesome  structure:  Gray,  in 
a  careful  paper,  states  that  150  cases 
of  intestinal  obstruction  caused  by  it 
were  reported  between  1893  and  1906. 
"  From  10  to  20  years  appears  to  be 
the  age  at  which  these  accidents  are 
most  common.  It  is  also  liable  to 
acute  inflammation,  or  diverticulitis, 
which  is  as  dangerous  as  acute  ap- 
pendicitis." 

There  are  few  structures  in  our 
bodies  more  capable  of  exciting  philo- 
sophical speculation  than  the  yolk-sac 
and  its  duct.  This  organ  may  in  man  and  all  the  higher 
mammals  be  regarded  as  vestigial,  for  its  duties  have  been 
in  part  abrogated  by  the  allantois,  but  more  completely  by 
the  placenta.  In  the  human  embryo  it  is  the  function  of 
the  allantois  to  convey  the  blood-vessels  which  it  receives 
from  the  developing  aorta  and  distribute  them  to  those 
chorionic  villi  destined  to  form  the  foBtal  portion  of  the 
placenta. 

In   some   sharks   the   yolk-sac   is  covered  with   vascular 


Fig.  319.  —  A  Meckers 
diverticulum  containing 
concretions  ;  it  commu- 
nicated "with  the  lumen 
of  the  ileum  by  a  narrow 
oijening  protected  by  a 
valve.    {After  Sherren.) 


IMPERFORATE  ILEUM 


597 


villous  tufts  wliicli  fit  into  depressions  of  the  oviduct.  Even 
in  some  mammals — e.g.  guinea-pigs — the  yolk-sac  enters  into 
vascular  connexion  with  the  uterine  mucous  membrane. 
There  are  abundant  and  good  reasons  for  Balfour's  conclusions 
that  placental  mammals  are  descendants  of  forms  the  em- 
br3^os  of  which  had  large  yolk-sacs;  but  the  yolk  became 
reduced  in  quantity  owing  to  the  nutriment  the  embryo 
received  from  the  maternal  tissues  by  means  of  the  vascular 
connexion   of   the    yolk-sac  with  the   uterine  wall.     Subse- 


Fig.  320.— Septate  ileum.     {Museum  of  the  Middlesex  Rospital.) 

quently  the  function  of  the  yolk-sac  became  limited  by  the 
allantois  and  the  gradual  evolution  of  the  placenta,  and 
finally,  so  far  as  man  is  concerned,  abolished.  Thus  in  man 
it  is  vestigial,  and,  like  such  structures  in  general,  is  liable  to 
many  vagaries. 

There  is  good  reason  to  believe  that  the  vitello-intestinal 
duct,  besides  being  a  source  of  cysts,  is  also  responsible  for 
the  curious  defect  in  t,he  ileum  to  which  I  have  applied  the 
name  imperforate  ileum.  It  occasionally  happens  that  the 
lumen  of  the  ileum  is  interrupted  by  a  perforated  diaphragm 
(Fig.  320).     To  such  a  condition  the  term  septate  ileum  is 


598  TVBULO-GYSTS 

applicable.  When  such  a  diaphragm  is  present  its  situation 
is  so]iietimes  indicated  by  a  marked  constriction  of  the  gut. 
In  other  specimens  a  more  or  less  perfect  valve  of  this  kind  is 
associated  with  a  persistent  duct.  In  such  cases  the  duct 
opens  into  the  ileum  on  the  distal  side  of  the  valve.  In  other 
instances  the  ileum  becomes  greatly  dilated  near  its  middle, 
and  the  walls  are  much  hypertrophied ;  to  this .  succeeds 
a  narrow  isthmus  which  opens  into  a  normal  segment  of 
ileum.  Lastly,  in  the  comjDlete  form  the  ileum  is  interrupted 
(Fig.  321). 


Proximal  segment 
of  ileum. 


Free  edge  of  mesentery. 


Distal  segment  of  ileum. 


Pig.  321. — Imperforate  ileum.     {Museum  of  the  Jliddlesex  JlosjjitaJ.) 

These  curious  defects  are  attributable  to  the  influence  of 
the  vitello-intestinal  duct,  because  they  always  occur  in  that 
portion  of  the  ileum  to  which  the  duct,  when  persistent,  is 
attached — that  is,  they  do  not  occur  within  30  cm.  of  the 
ileo-csecal  valve,  and  are  rarely  found  at  a  greater  distance 
than  1  metre  from  the  caecum. 

The  most  reliable  evidence  for  associating  these  defects 
with  the  duct  of  the  yolk-sac  is  that  furnished  by  specimens 
in  which  a  persistent  duct  and  a  valve  coexist.  In  my  early 
observations  I  had  regarded  imperforate  ileum  as  depending 


CYSTS   OF  TEE    UBAGHUS  599 

upon  the  influence  of  the  vitello-intestinal  duct,  and  sub- 
sequent observations  put  the  speculation  on  a  sound  basis. 
The  specimens  which  demonstrate  these  views  are  preserved 
in  the  museum  of  the  Middlesex  Hospital. 

Cysts  of  the  urachus. — The  urinary  bladder  of  man,  in 
common  with  that  of  other  mammals,  presents  at  its  apex  an 
impervious  cord  that  passes  to  the  umbilicus.  This  cord, 
known  as  the  urachus,  is  traversed  at  birth  by  a  narrow  canal 
lined  with  epithelium  directly  continuous  with  that  of  the 
bladder. 

The  urinary  bladder  with  the  urachus  is  the  persistent 
portion  of  the  allantois,  the  organ  which  in  the  early  embryo 
conveys  blood-vessels  from  the  aorta  to  the  developing 
placenta.  In  the  adult  the  urachus  lies  in  the  subperitoneal 
tissue  exactly  in  the  middle  line  of  the  anterior  abdominal 
wall,  between  the  summit  of  the  bladder  and  the  umbilicus. 
When  the  urachus  becomes  dilated  it  forms  a  cyst  lying 
outside  the  peritoneum  and  in  close  relation  with  the 
bladder. 

Instead  of  a  portion  of  the  allantois  narrowing  to  form  a 
urachus,  the  whole  of  its  intra-abdominal  portion  may  dilate 
and  form  a  large  urinary  bladder. 

Several  cases  are  known  in  which  the  umbilical  end  of  the 
urachus  has  remained  patent,  so  that  urine  was  voided  at  this 
spot.  A  urinary  calculus  has  been  extracted  from  such  a 
persistent  urachus. 

Cj^sts  of  the  dimensions  of  a  cherry  are  not  uncommon 
in  the  urachus,  especially  near  the  summit  of  the  bladder; 
sometimes  a  number  of  small  dilatations  occur,  causing  the 
urachus  to  assume  a  moniliform  appearance. 

In  rare  cases  the  urachus  may  dilate  into  a  cj'st  as  large 
as  a  distended  bladder.  The  walls  of  such  cysts  are  composed 
of  unstriped-muscle  tissue.  The  surgeon  must  be  on  his  guard 
not  to  confound  a  sacculus  at  the  apex  of  the  bladder,  or 
extending  into  the  suspensory  ligament,  with  a  cyst  arising 
in  the  urachus. 

Lawson  Tait  drew  attention  to  the  probable  origin  of  some 
forms  of  extraperitoneal  cysts  in  the  urachus,  and  the  whole 
matter  has  been  subjected  to  a  very  critical  and  painstaking 
analysis  by  Doran. 


600  TUBUL0-GYST8 

Allantoic  (urachus)  cysts  not  only  occur  in  man,  but  I 
have  observed  them  also  in  the  pig,  horse,  ox,  and  mole. 

Ci/sts  of  AliUler's  ducts. — In  many  vertebrata  the  eggs,  after  their 
escape  from  the  ovary,  are  conveyed  to  the  exterior  by  means  of  a 
muscular  conduit  known  as  the  oviduct.  The  general  disposition  of 
these  ducts,  for  there  are  usually  two,  may  be  gathered  from  an  exam- 
ination of  a  female  frog  or  toad.  The  ducts  extend  from  the  cloaca 
posteriorly  to  the  roots  of  the  lungs  anteriorly ;  they  are  supported  on 
the  dorsal  wall  of  the  abdomen  by  means  of  a  delicate  fold  of  peri- 
toneum, and  each  duct  communicates  with  the  peritoneal  cavity  by  a 
dilated  orifice  known  as  the  infundibulum.  In  the  breeding  season  the 
ducts  become  greatly  enlarged  and  convoluted,  resembling  coils  of 
small  intestine. 

Normally,  oviducts  are  present  in  the  female  only.  It  is,  however, 
remarkable  that  the  embryos  of  those  forms  in  which  the  sexes  are 
distinct  in  the  adult  condition  have  the  rudiments  of  the  sexual  organs 
peculiar  to  the  male  and  female  ;  they  are  hermaphrodite.  As  develop- 
ment continues,  one  set  of  organs  usually  attains  a  functional  condition  ; 
the  other  atrophies  more  or  less  completely. 

The  distinguishing  features  of  the  ihternal  sexual  organs  of  a  female 
frog  are  two  ovaries  and  two  oviducts.  In  the  male  the  oviducts  are 
usually  absent.  It  is,  however,  an  interesting  fact  that  in  many  male 
frogs  the  oviducts  may  be  detected  as  thin,  delicate  threads  ascending 
in  the  peritoneum  from  the  structures  called  vesiculae  seminales  to  the 
roots  of  the  lungs.  Sometimes  the  ducts  are  of  large  size,  almost  equal 
to  the  oviducts  in  the  female.  Persistent  MLillerian  ducts  are  more 
common  in  male  toads  than  in  frogs.  Often  they  are  associated  with 
the  malformation  of  the  genital  gland  known  as  an  ova-testis  ;  but  they 
are  fairly  frequent  even  when  the  genital  gland  is  a  typical  testis.  No 
one  can  doubt  that  an  oviduct  in  a  male  frog  or  toad  is  functionless, 
and  it  is  not  uncommon  to  meet  with  small  dilatations  or  cysts  lying  in 
the  track  of,  and  arising  from,  the  functionless  oviducts.  Persistent 
Miiller's  ducts  are  by  no  means  confined  to  batrachians,  but  they  have 
been  observed  in  fish,  lizards,  stallions,  birds,  and  men. 

Good  examples  of  cysts  arising  in  functionless  ducts  are  sometimes 
met  with  in  birds.  In  birds,  as  in  frogs  and  toads,  the  eggs  are  con- 
veyed to  the  exterior  by  means  of  an  oviduct,  but  in  the  case  of  birds 
the  duct  is  functional  on  the  left  side  only.  Each  chick  has  two 
oviducts,  but  the  right  ovary  and  duct,  from  some  unexplained  cause, 
atrophies,  leaving,  as  a  rule,  a  small,  narrow  tubule  surmounted  by  a 
lobule  of  fat.  This  remnant  of  the  right  duct  is  very  apt  to  dilate  and 
form  a  cyst.  When  the  stump  of  the  duct  is  longer  than  usual  it  will 
sometimes  become  unequally  dilated  and  form  a  chaplet  of  cysts. 

Bland-Sutton,  J.,  "  Abstract  of  the  Erasmus  Wilson  Lectures  on  the  Value  of 
Comparative  Pathology  to  Philosophical  Surgery  "  :  Lecture  l.Srit.  Med. 
Jour)i.,  1891,  i.  342. 


11EFEBENGE8  601 

Doran,  A.,  "  Urachal  Cysts."  -Proc.  Roy.  Soc.  Med.,  Surgical  Section,  1909,  ii. 
198. 

Gray,  H.  T.,  "Some  Cases  in  which  Meckel's  Diverticulum  was  present." — 

Brit.  Med.  Journ.,  1907,  ii.  823. 
Paget,  T.,  "A  Case  in  which  the  Urachus  remained  open,  and  a  ring-shaped 

Calculus,  formed  upon  a  Hair  in  the  Bladder,  was  extracted  through  the 

Umbilicus."     Communicated   by   William    Bowman,   F.R.S. — Med.-Chir. 

Trans.,  1850,  xxxiii.  293. 

Sherren,  J.,  "  Meckel's  Diverticulum  containing'  Calculi  and  producing  Colic." 
— ProG.  Roy.  Sog.  Med.,  Clinical  Section,  1910,  iii.  11. 


CHAPTER    LVIII 

HYDROCELE 

The  name  hydrocele  is  applied  to  several  different  kinds  of 
cystic  tumours,  and  as  the  term  is  so  deeply  rooted  in  surgical 
literature  it  would  be  very  inconvenient  to  attempt  to  dis- 
card it.  In  this  work  it  will  be  restricted  to  cysts  clue  to  an 
excessive  accumulation  of  fluid  in  a  diverticulum  or  pouch  of 
the  peritoneum,,  such  as — 1,  hydrocele  of  the  tunica  vaginalis; 
2,  hydrocele  of  the  canal  of  Nuck ;  3,  ovarian  hydrocele ; 
4,  omental  hydrocele. 

1.  Hydrocele  of  the  tunica  vaginalis. — Each  testicle 
is  preceded  in  its  descent  by  a  diverticulum  of  the  parietal 
peritoneum,  which  enters  the  scrotum  by  way  of  the  inguinal 
canal.  As  the  testicle  descends  behind  this  diverticulum,  or 
funicular  pouch,  as  it  is  termed,  it  invaginates  the  membrane 
in  such  a  way  as  to  invest  the  anterior  two-thirds  of  its  surface 
with  a  double  layer  of  peritoneum.  When  the  testicle  first 
gains  the  scrotum  the  funicular  pouch  is  in  free  communica- 
tion with  the  general  peritoneal  cavity.  It  is  a  remarkable 
fact  that  in  almost  every  mammal,  male  and  female,  save 
man,  this  relation  of  the  funicular  pouch  to  the  peritoneal 
cavity  persists  throughout  life.  The  only  exceptions  which 
have  come  under  my  notice  occurred  in  a  chimpanzee  and  a 
gorilla. 

In  exceptional  instances  this  communication  persists 
throughout  life  even  in  man.  Normally  the  peritoneum  be- 
comes adherent  immediately  above  the  testis,  this  adhesion 
dividing  the  pouch  into  two  parts ;  the  portion  in  relation  with 
the  testis  persists  throughout  life  as  the  tunica  vaginalis, 
whilst  that  above  the  testis  usually  undergoes  obliteration  in 
the  course  of  the  early  months  of  infant  life. 

Normally,  then,  the  only  portion  of  the  funicular  pouch 
which  persists  throughout  life  is  that  in  immediate  relation 

602 


HYDROGELES  603 

with  the  testis,  and  when  it  becomes  distended  with  fluid  it 
is  termed  Itydrocele  of  the  tunica  vaginalis.  When  contain- 
ing blood  it  is  called  Jicumatocele  of  the  tunica  vaginalis. 
Should  the  whole  of  the  funicular  pouch  persist  and  be- 
come occupied  by  fluid,  it  is  called  a  congenital  hydrocele. 
Frequently  the  tunica  vaginalis  is  formed  as  usual,  but  the 
portion  intervening  between  it  and  the  internal  abdominal 
ring  persists  and  may  become  distended  with  fluid.  This 
is  known  as  funicular  hydrocele;  it  is  often  called  encysted 
hydrocele  of  the  cord. 

Hydrocele  of  the  tunica  vaginalis  appears  in  two  forms, 
acute  and  chronic.  Acute  hydrocele  is  due  to  inflammatory 
effusion  into  the  sac,  either  the  result,  of  injury  or  secondary 
to  acute  orchitis.  This  is  the  rarer  form,  and,  as  a  rule,  the 
fluid  is  absorbed  and  the  parts  return  to  their  normal 
condition  as  the  inflammatory  trouble  that  caused  it  subsides. 
Exceptionally  a  hydrocele  appearing  in  this  way  persists. 

The  common  form  of  hydrocele  is  a  passive  effusion  into 
the  tunica  vaginalis,  usually  appearing  about  the  middle 
period  of  life,  and  in  many  cases  without  any  exciting  cause, 
either  local  or  constitutional.  It  is  very  common  in  men  who 
have  lived  in  the  tropics.  Hydrocele  is  met  with  in  extreme 
old  age,  and  is  occasionally  bilateral. 

The  amount  of  fluid  in  hydroceles  varies  greatly  ;  in  some 
it  amounts  to  one  or  two  ounces,  whilst  in  others  it  mea- 
sures a  pint  or  more.  The  fluid  is  limpid,  of  a  straw  colour, 
with  a  specific  gravity  of  about  1015.  It  contains  a  large 
amount  of  albumin  and  the  substance  known  as  fibrinogen. 
When  allowed  to  stand  after  withdrawal  it  spontaneously 
coagulates. 

When  the  fluid  is  removed  by  tapping  it  usually  quickly 
reaccumulates,  so  that  the  amount  of  fluid  furnished  by  a  large 
hydrocele  in  the  course  of  a  few  years  is  often  considerable. 
A  native  of  the  Gold  Coast  had  a  hydrocele  of  the  tunica 
vaginalis  which  contained  fifteen  pints  of  fluid  (Horn). 

The  presence  of  a  large  quantity  of  fluid  in  the  tunica 
vaginalis  leads  to  changes  not  only  in  the  membrane  itself 
but  also  in  the  testicle,  for  this  gland,  pressed  upon  by  the 
fluid,  will  in  course  of  time  atrophy.  In  most  specimens  the 
testis  is  situated  in  the  lower  and  back  part  of  the  sac,  as  in 


604 


CYSTS 


Fig.  322.  In  those  cases  in  wliich  the  testis  is  inverted  the 
hydrocele  projects  posteriorly,  and  the  testis  lies  in  front  and 
at  the  upper  part  of  the  sac. 

In  addition  to  atrophy  of  the  testis,  there  may  be  great 
thickening  of  its  tunica  albuginea,  a  condition  termed  peri- 
orchitis, which  may  mask  the  diminution  in  the  size  of  its 
secreting  tissue,  and  is  by  no  means  infrequent  in  old  hydro- 
celes, especially  those  which   have   been   repeatedly  tapped. 


Covering  of 

the  cord 


Cremaster  muscle. 


Tunica  vaginalis. 


Fig.  322. — Hydrocele  of  the  tunica  vaginalis  testis. 


This  thickening,  or  sclerosis,  manifested  by  the  immediate 
covering  of  the  testis,  is  often  seen  in  the  tunica  vaginalis 
throughout  its  whole  extent,  and  in  some  cases  this  mem- 
brane may  be  as  thick  and  almost  as  hard  as  pasteboard. 
The  hardness  of  these  thick  sacs  is  sometimes  increased  by 
calcareous  matter.  When  such  sacs  are  dissected  out  they  are 
not  unlike  a  coco-nut  in  shape,  size,  and  consistence.  Second- 
ary changes  of  this  kind  are  attributed  to  repeated  attacks 
of  inflammation  set  up  by  tapping :  in  some  cases  bands  of 
adhesions  or  broad  septa  form,  and  produce  a  loculated  cj^st. 


HYDB0GELE8  605 

In  other  cases  suppuration  ensues,  which  may  lead  to  serious 
consequences.  Occasionally,  loose  bodies  are  found  in  the  sac 
of  the  tunica  vaginalis,  often  associated  with,  but  sometimes 
independent  of,  hydroceles.  Some  are  no  larger  than  the 
head  of  a  pin,  others  attain  the  dimensions  of  a  cherry.  The 
larger  examples  consist  of  dense,  structureless  laminae. 

Rupture  of  a  hydrocele. — This  is  a  rare  accident,  and  is 
the  result  of  slight  injury  or  a  nmscular  strain  ;  in  some  cases 
it  appears  to  have  happened  spontaneously.  Hastings  has 
collected  forty  cases,  and  the  records  show  that  the  accident 
occurs  mainly  in  chronic  hydroceles  and  is  associated  with 
degenerative  changes  in  their  tunics. 

In  two  cases  under  my  care  the  patients  complained  of  pain, 
followed  by  oedema,  and,  some  hours  later,  ecchymosis  of  the 
scrotum  due  to  extravasation  of  the  fluid  into  its  loose  tissues. 
One  of  the  men  burst  his  hydrocele  when  stooping  to  pick 
up  a  sixpenny-piece ;  the  other  crushed  his  scrotum  against 
the  corner  of  the  table  when  playing  bilhards. 

The  variety  known  as  congenital  hydrocele  is  due  to  the 
persistence  of  the  funicular  pouch  throughout  its  whole  extent. 
In  this  form  we  meet  with  two  conditions :  the  sac  may 
retain  its  connexion  with  the  general  peritoneal  cavity,  or  it 
may  be  occluded  at  the  internal  abdominal  ring.  When  the 
orifice  of  the  sac  is  not  occluded,  the  fluid  which  accumulates  in 
the  sac  gravitates  into  it  from  the  peritoneal  cavity  during  the 
day  ;  but  during  the  night,  when  the  body  has  been  in  a 
recumbent  position  for  a  prolonged  period,  the  fluid  returns 
wholly  or  in  part  to  the  abdomen,  so  that  in  the  morning 
the  scrotal  swelling  will  be  found  greatly  diminished,  if  not 
entirely  gone.  As  the  day  goes  on  the  fluid  will  slowly  re- 
accumulate  in  the  tunica  vaginalis.  Such  alteration  in  size 
of  the  swelling  is  characteristic  of  this  variety  of  hydrocele  • 
but  it  is  sometimes  simulated  by,  and  mistaken  for,  an  ingui- 
nal hernia.  A  child  under  my  observation  had  tuberculous 
peritonitis  and  a  congenital  hydrocele :  the  peritoneal  fluid 
infected  the  hydrocele-sac  with  tubercle.  I  removed  the 
testis,  its  cord  and  coverings,  and  found  tubercle  bacilli  in 
the  lesions. 

When  the  funicular  pouch  is  shut  off  at  the  inguinal  canal 
and  becomes  distended  with  fluid,  it  is  sometimes  diflicult  to 


606  .  GYST8 

distinguish  it,  except  by  dissection,  from  a  hydrocele  of  the 
tunica  vaginalis. 

Congenital  hydrocele  is  most  commonly  met  with  in 
children,  and  is  very  rare  after  the  fifteenth  year.  An  accumu- 
lation of  fluid  is  not  uncommon  in  the  funicular  pouch  of 
infants,  and  it  often  disappears  spontaneously. 

Funicular  hydrocele  is  another  variety,  frequently  referred 
to  as  encysted  hydrocele  of  the  cord.  It  is  due  to  effusion  of 
fluid  into  that  portion  of  the  funicular  pouch  which  intervenes 
between  the  tunica  vaginalis  and  the  internal  abdominal 
rinsT,  and  which,  under  normal  conditions,  suffers  obliteration. 
This  form  of  hydrocele  is  very  frequent  in  infants,  and  presents 
itself  as  an  ovoid  tumour  lying  between  the  testis  and  the 
inguinal  canal.  Although  it  possesses  very  characteristic 
features,  tliis  variety  of  hydrocele  is  frequently  confounded 
with  hernia  of  the  intestines  into  the  funicular  pouch. 
Funicular  hydroceles  occasionally  occur  in  j^oung  adults. 

It  should  be  borne  in  mind  that  an  inguinal  hernia  may 
be  associated  with  a  hydrocele,  and  it  happens  occasionally 
that  the  neck  of  a  hernial  sac  becomes  so  narrowed  that 
gut  and  omentum  no  longer  pass  through  it.  A  pouch  of  this 
kind  would,  if  distended  with  fluid,  simulate  a  hydrocele  of 
the  tunica  vaginalis ;  it  is  known  as  hydrocele  of  a  hernial 
sac.  According  to  Horrocks,  the  large  scrotal  cyst  which 
troubled  Gibbon,  the  historian,  was  an  irreducible  hernia  with 
a  large  quantity  of  fluid  in  the  sac. 

2.  Hydrocele  of  the  canal  of  Nuck. — In  female  fcetusea 
a  diverticulum  of  the  parietal  peritoneum  descends  into  the 
inguinal  canal,  and  is  in  all  respects  identical  with  the 
funicular  pouch  in  the  male  ;  it  is  known  as  the  canal  of 
Nuck.  Usually  this  pouch  becomes  obliterated,  but  it  is  by 
no  means  rare  to  find  it  patent  in  young  women.  Occasionally 
the  canal  becomes  distended  with  fluid  and  forms  a  cyst 
occupying  the  inguinal  canal,  and  is  then  termed  a  hj'drocele 
of  the  canal  of  Nuck. 

Treatment  of  hydrocele. — The  routine  practice  of  treating 
a  hydrocele  of  the  tunica  vaginalis  is  to  draw  off  the  fluid  by 
means  of  a  narrow  trocar  and  cannula.  The  cyst  almost  in- 
variably refills,  necessitating  repeated  tapping.  The  simplest 
method  is  to   open   the   sac,  and,  after  inverting  the  tunica 


HYDROGELE'S  607 

vaginalis,  return  it  with  the  testis  into  the  scrotum.  This  is 
also  the  most  appropriate  method  of  treatment  for  rupture  of 
the  tunica  vaginalis  testis.  Nash  has  shown  that  rupture 
of  the  tunica  vaginalis  does  not  often  cure  the  hydrocele. 
Hydrocele  of  the  canal  of  Nuck  should  be  dissected  out  and 
the  neck  of  the  sac  ligatured.  The  same  method  answers  well 
for  hydrocele  of  a  hernial  sac,  whether  inguinal  or  femoral. 

3.  Ovarian  hydrocele. — The  ovaries  in  rats  and  mice 
are  contained  within  a  serous  sac  derived  from  the  peritoneum. 
The  abdominal  ostium  of  the  Fallopian  tube  communicates 
with  the  ovarian  sac ;  hence,  when  the  ova  escape  from  the 


Ovarian  hydrocele  in  a  rat.     (Nat.  size.) 


ovary  they  enter  the  Fallopian  .tube  and  gain  the  uterus 
without  entering  the  general  peritoneal  cavity,  as  is  the  case 
with  the  human  ovum.  This  serous  sac  investment  of  the 
ovary  recalls  the  tunica  vaginalis  of  the  testicle,  and,  like 
it,  the  ovarian  sac  is  liable  to  become  distended  Avith  serous 
fluid,  a  condition  to  which  I  have  applied  the  name  ovarian 
hydrocele.  Cysts  of  this  kind  in  rats  may  attain  a  large  size, 
and  their  general  features  are  well  illustrated  in  Fig.  323- 
The  Fallopian  tube  in  the  rat  is  coiled  up  between  the  cornu 
of  the  uterus  and  the  ovarian  sac,  but  when  the  sac  be- 
comes distended  it  uncoils  the  tube  and  stretches  it  around 
the  circumference  of  the  cyst ;  the  tubal  ostium  opens 
on  the  inner  wall  of  the  hydrocele,  and  the  adjacent  section 


608  CYSTS 

of  the  tube  is,  as  a  rule,  dilated.  The  ovary,  when  the  cyst  is 
small,  projects  into  the  cysts,  but  in  very  large  hydroceles  it 
atrojohies  from  pressure.  As  the  ovarian  sac  is  in  communica- 
tion with  the  uterine  cornu  it  sometimes  becomes  implicated 
in  septic  conditions  of  the  uterus,  and  the  sac  may  be  found 
distended  with  pus. 

No  other  mammal  normally  possesses  such  a  complete 
ovarian  sac  as  do  rats  and  mice,  but  many  have  a  pouch  that 
communicates  with  the  general  peritoneal  cavity  by  a  small 
aperture ;  in  others  the  pouch  has  a  narrow  slit ;  whilst  in 
women  the  ovar}^,  in  its  virgin  condition,  lies  in  a  shallow 
recess.  Notwithstanding  the  fact  that  the  mouth  of  the 
ovarian  pouch  is  in  women  very  wide,  there  is  good  reason  to 
believe  that  its  edges  may  unite  when  the  pouch  is  abnormally 
deep  and  convert  it  into  a  closed  sac,  which  subsequently 
becomes  a  hydrocele.  Ovarian  hydroceles  occur  in  the  human 
female,  and  sometimes  attain  a  large  size.  They  present  the 
following  anatomical  features : — 

The  sac  projects  from,  and  is  intimately  connected  with, 
the  posterior  layer  of  the  broad  ligament.  In  small  hydro- 
celes the  ovary  projects  into  the  cavity  of  the  cyst,  but  in 
large  examples  it  is  atrophied.  The  Fallopian  tube  lies  on 
the  crown  of  the  cyst,  its  outer  half  is  dilated  and  tortuous ; 
the  ostium  opens  into  the  hydrocele  by  a  large  circular  or 
elliptical  ajDerture.  Ridges  of  mucous  membrane  issue  from 
the  interior  of  the  tube  and  pass  on  to  the  walls  of  the 
hydrocele  in  a  radiating  fashion.  AVhen  the  specimens  are 
examined  in  a  fresh  state  it  is  not  rare  to  find  the  aperture 
fringed  with  tubal  fimbria.  The  general  appearance  of  a 
typical  ovarian  hj^drocele  suggests  "  a  retort  with  a  convoluted 
delivery-tube  "  (Grifiith). 

Besides  finding  ovarian  hydroceles  in  rats  and  women,  I 
have  detected  one  in  a  guinea-pig,  and  Schneidemlihl  has 
observed  one  in  a  mare. 

The  cysts  liable  to  be  confounded  with  ovarian  hydroceles 
are  parovarian  cysts,  small  paroophoronic  cysts,  and  large 
hydrosalpinges.  A  parovarian  or  paroophoronic  cystis  distin- 
guished from  a  hydrocele  of  the  ovary  by  the  fact  that  the 
Fallopian  tube  is  stretched  across  the  cyst  but  does  not 
communicate  with  its  cavity. 


HYDROCELES  609 

In  the  case  of  a  large  hydrosalpinx  the  ampulla  is  often 
so  flexed  on  the  tube  as  to  produce  a  retort-shaped  cyst ;  but 
there  are  no  fringes  or  ridges  of  the  mucous  membrane  at  the 
orifice  of  communication,  and  the  ovary  lies  free  of  the  cyst- 
wall  and  is  often  lodged  in  the  flexure  of  the  tube. 

Ovarian  hydroceles  must  not  be  confounded  with  tubo- 
ovarian  cysts  and  abscesses  the  result  of  salpingitis. 

4.  Omental  hydrocele. — Under  normal  conditions  the 
lesser  cavity  of  the  peritoneum  extends  into  the  great  omen- 
tum ;  occasionally  this  space  becomes  distended  with  fluid, 
and  its  communication  with  the  upper  area  of  the  lesser 
cavity  becoming  shut  ofl",  the  omental  space  is  isolated  and 
converted  into  a  cyst.  Similar  cysts  arise  in  the  transverse 
mesocolon,  and  I  have  encountered  them  in  the  mesocsecum 
and  mesosigmoid.  Omental  hydroceles  are  sometimes  so 
big  as  to  simulate  ovarian  tumours. 

Chyle-cysts. — This  is  perhaps  the  best  place  to  mention 
a  rare  but  interesting  lesion  known  as  chyle-cyst  of  the 
mesentery.  The  sac  of  the  cyst  appears  to  be  formed  of 
the  separated  layers  of  the  mesentery,  the  interspace  being 
occupied  by  fluid  identical  in  its  physical  and  chemical 
characters  with  chyle.  In  their  anatomical  features  these 
cysts  are  similar  to  omental  hydroceles,  and,  like  them,  are 
occasionally  big  enough  clinically  to  simulate  ovarian  cysts 
(Rasch,  Bramann,  Mendes  de  Leon,  and  Fetherston). 

There  is  a  variety  of  cyst  containing  chyle  which  is  met 
with  in  infants  and  children.  Such  cysts  are  closely  con- 
nected with  the  mesenteric  border  of  the  intestine  and  push 
their  way  between  the  layers  of  the  mesentery.  There  is 
reason  to  believe  that  they  arise  as  abstrictions  of  the  in- 
testines during  fcetal  life.  This  variety  has  been  particularly 
studied  by  Eve,  Fawcett,  and  Dowd.  These  cysts  are  im- 
portant, for  they  have  caused  fatal  intestinal  obstruction. 


Bland-Sutton,  J.,  "  Inguinal  Hernia  in   Monkeys." — Trans.  Path.   Soc,  1888, 
xxxix.  453. 

Bramann,  F.,  "  Ueber  Chyluscysten  des  Mesenteriums." — Arch.f.Miti.  Chir., 

1887,  XXXV.  204. 
Doran,  A.,  "  Cyst  of  the  Great  Omentum."— Tra?*.'.  Obstet.  Soc,  Zond.,  1881-82, 

xxiii.  164. 
Dowd,  C.  N.,  "Mesenteric  Cysts." — Aoin.  of  Surg.,  1900,  xxxii.  51. 
2  N 


eiO  CYSTS 

Eve,  F.  S.,  "On  Mesenteric  Cysts  ;  with  two  cases  in  young  children  subjected 

to  operation." — Med.-Chir.  Trans.,  1898,  Ixxxi.  51. 
Fawcett,  J.,  "'Chyle'  Cyst  of  Mesentery;   Intestinal  Obstruction." — Trans. 

Path.  Soc,  1902,  liii.  406. 
Fetherston,   R.   H.,  "A   Case  of    Chyle  Cyst  of   the    Mesentery." — Austral. 

Med.  Journ.,  1890,  xii.  475. 
Frankl,*  "  Einiges  iiber  die  Involution  des  Scheidenfortsazes  und  die  Hullen 

des  Hodens." — Arcli.f.  Anat.  und  Entwich.,  1895,  p.  339. 
Hastings,  S.,  "Rupture  of  the  Tunica  Vaginalis  in  Hydroceles." — Froc.  Roy. 

Soc.  Med.,  Surgical  Section,  1910,  iii.  165. 
Horn,  A.  E.,  "A  Pifteen-Pint  Hydrocele."— ^T-iiJ.  Med.  Journ.,  1907,  ii.  143. 
Horrocks,  W.,  "Medical  Notes  on  the  Life  of  Edmund  Gibbon,  the  Historian." 

—Lancet,  1901,  i.  1356. 
Mendes  de  Leon,  "A  Case  of  Chyle  Cyst." — Amer.  Journ.  Ohstet.,  1891,  xxiv. 

168. 
Moynihan,  B.  G.  A.,  "Mesenteric  Cysts." — Ann.  of  Surg.,  1897. 
Nash,  W.  G.,  "  Repeated  Rupture  of  the  Tunica  Vaginalis." — Brit.  Med.  Journ., 

1907,  ii.  1065. 
Rasch,  A.,  "  A  Case  of  Large  Chylous  Cyst  of  the  Mesentery." — Trans.  Ohstet. 

Soc,  1889-90,  xxxi.  311. 
Robinson,  A,,  "  On  the  Peritoneal  Relations  of  the  Mammalian  Ovary." — Joiirn. 

of  Anat.  and  Phys.,  sxi.  169. 

*  Frankl  regards  the  xiew  of  the  relations  of  the  testicle  to  its  membranes 
which  is  set  out  on  page  602  as  erroneous.  His  investigations  show  that  the  body 
of  the  testis  in  the  embryo  projects  into  the  peritoneal  cavity,  and  its  intraperi- 
toneal surface,  hke  that  of  the  ovary,  is  covered  with  involuting  germ- epithelium. 
The  body  of  the  descended  testis  projects  into  the  funicular  jDOuch,  but  it  is  not 
covered  by  the  serous  membrane.  The  only  part  of  the  testicle  invested  with 
peritoneum  is  the  epididymis.  The  body  of  the  testis  has  a  peritoneal  envelope,  but 
not  a  peritoneal  covering. 


CHAPTER  LIX 

PSEUDO-CYSTS 

DIVERTICULA 

The  term  diverticulum  is  used  to  denote  hernia  or  protrusion 
of  the  Hning  membrane  of  a  cavity  through  a  defective  spot 
in  its  walls.  Such  protrusions  occur  in  connexion  with  the 
oesophagus  and  intestines,  the  bladder,  and  the  trachea ;  also 
in  relation  with  joints  and  tendon-sheaths,  forming  synovial 
cysts  and  ganglia;  and  in  blood-vessels,  forming  sacculated 
aneurysms  and  varices. 

Intestinal  diverticula. — These  are  hernial  protrusions  of 
the  mucous  membrane  of  the  bowel  through  interspaces  in  the 
muscular  coat.  Structurally  they  consist  of  mucous  membrane 
with  a  covering  of  peritoneum.  Sometimes  a  few  strands  of 
muscle-fibre  can  be  detected  stretched  across  the  pouch. 

Frequently  diverticula  occur  in  multiples ;  as  many  as  two 
hundred  have  been  found  in  one  case.  These  pouches  occur 
in  all  parts  of  the  intestine,  but  are  most  frequent  in  the 
colon,  and  especially  about  the  sigmoid  flexure.  In  the  small 
intestine  they  usually  occur  along  the  line  of  the  attachment 
of  the  mesentery.  In  the  colon  they  are  found  about  the 
attachment  of  the  appendices  epiploicse,  and  may  even  project 
into  them. 

In  dimensions  diverticula  vary  greatly — some  are  as  small 
as  peas,  others  as  large  as  oranges.  When  the  pouches  are 
numerous,  as  a  rule  they  are  small ;  when  few  in  number,  or 
solitary,  they  may  be  large.  Intestinal  diverticula  are  common 
in  old  persons,  but  they  rarely  lead  to  serious  consequences. 

Some  writers  describe  diverticula  of  the  intestines  as  con- 
sisting of  two  varieties,  true  and  false.  According  to  this 
arrangement  a  persistent  vitello- intestinal  duct  would  be 
called  a  true  diverticulum. 

611 


612  PSBUD0-CT8T8 

Vesical  diverticula. — Hernial  protrusions  of  tlie  mucous 
membrane  of  the  bladder  between  the  fasciculi  of  the  muscular 
coat  are  of  frequent  occurrence.  The  cause  of  the  protrusion 
is  impediment  to  the  free  flow  of  urine  :  the  obstruction  may- 
be seated  in  the  urethra  or  at  the  neck  of  the  bladder.  Under 
such  conditions  there  may  be  several  diverticula;  the  bladder 
is  then  said  to  be  sacculated.  Sometimes  there  is  only  one 
saccule,  and  this  may  attain  a  large  size.  Vesical  diverticula 
usually  communicate  with  the  cavity  of  the  bladder  by  large 
orifices.  A  sacculus  extending  into  the  suspensory  ligament 
of  the  bladder  must  not  be  confounded  with  a  urachus  cyst. 

Sacculated  bladders,  apart  from  the  cause  that  produces 
the  sacculi,  do  not  often  give  rise  to  trouble.  Calculi  are 
sometimes  found  within  them,  and  in  cases  where  the  outflow 
of  urine  is  seriously  obstructed  the  walls  of  a  sacculus  will 
sometimes  yield  and  allow  the  urine  to  extravasate  into  the 
surrounding  loose  connective  tissue. 

As  impediments  to  the  free  escape  of  urine  from  the 
bladder  occur  more  frequently  in  men  than  in  women,  it 
naturally  follows  that  sacculated  bladders  are  more  common 
in  men.  Nevertheless,  vesical  diverticula  of  large  size  are 
occasionally  found  in  women,  and  in  exceptional  cases  have 
caused  death. 

Pharyngeal  diverticula  (pharyngoceles). — Localized  dila- 
tations of  the  pharynx  are  of  three  kinds  : — 

Abnormal  persistence  and  distension  of  certain  pouches 
which,  as  a  rule,  exist  in  the  embryo  only — e.g. 
the  pouch  of  Rathke  and  the  branchial  clefts. 

Pouching  of  the  pharyngeal  wall  at  its  junction  with  the 
oesophagus. 

Protrusions  (hernise)  of  the  mucous  membrane  lining 
Rosenmiiller's  fossa. 

When  the  pouch  of  Rathke  persists  it  may  dilate  and  form 
a  cyst  in  the  pharynx  near  the  junction  of  its  posterior  wall 
with  the  roof.  Such  cysts  have  been  known  to  attain  the 
dimensions  of  a  ripe  cherry. 

In  order  to  appreciate  the  nature  of  at  least  one  form 
of  pharyngeal  pouch  it  will  be  necessary  to  take  into 
consideration  an  interesting  congenital  defect  to  which  the 
pharynx  is  liable. 


PHARYNGOGELES 


613 


It  occasionally  happens  that  children  are  born  with  what 
is  known  as  an  imperforate  pharynx,  that  is,  instead  of 
the  pharynx  and  cBsophagus  forming  a  continuous  tube,  the 
pharynx  terminates  as  a  cul-de-sac  near  the  level  of  the  cri- 


coid cartilage. 


In  such  cases  the  upper  end  of  the  oesophagus  terminates 
by  opening  into  the  trachea  through  its  posterior  wall.     The 


Aperture  by 

which  the 
oesophagus 
communicates 
with  the  trachea. 


Fig.  324. — Imperforate  pharynx. 


Fig.  325. — Pharyngeal  diverticulum. 
{After   Worthingtoii.) 


situation  of  the  oesophago-tracheal  fistula  varies  in  different 
specimens  ;  sometimes  it  is  as  high  as  the  third  tracheal  semi- 
ring, or  it  may  be  as  low  as  the  bifurcation  of  the  trachea,  and 
in  at  least  one  case  it  opened  into  the  left  bronchus.  In  most 
examples  of  imperforate  pharynx  the  oesophagus  is  connected 
with  the  lower  end  of  the  pharynx  by  a  fibrous  band,  which 
indicates  that  the  two  structures  were  originally  continuous 
but  that  their  continuity  has  been  disturbed  by  secondary 
changes  (Fig.  824). 

The  constant  association  of  an  oesophago-tracheal  fistula 
with  imperforate  pharynx  indicates  some  relation  between  the 


614  PSEUD0-GYST8 

two  conditions.  The  explanation  which  at  once  suggests 
itself  is,  that  it  may  be  due  to  some  influence  exercised  by 
the  pulmonary  diverticulum  which  leaves  that  portion  of  the 
embryonic  fore-gut  ultimately  represented  by  the  oesophagus. 
This  subject  has  been  handled  with  remarkable  acumen  by 
Shattock. 

It  is  necessary  to  describe  congenital  imperfections  at  the 
junction  of  the  pharynx  and  oesophagus,  because  it  is  at  this 
point  that  pouches  are  apt  to  form.  A  typical  example  of  a 
pharyngeal  pouch,  or  pharyngocele,  is  shown  in  Fig.  325. 
The  case  is  very  carefully  described  by  Worthington.  The 
parts  were  obtained  from  a  man  69  years  of  age.  There 
was  a  stricture  of  the  oesophagus  at  the  level  of  the  cricoid 
cartilage  that  would  admit  merely  a  urethral  bougie.  This 
obstruction  ultimately  led  to  the  death  of  the  patient.  He 
could  swallow  food  and  retain  it  for  a  time ;  it  would  then 
regurgitate.  At  the  post-mortem  dissection  the  pouch  was 
detected ;  it  was  in  shape  like  the  finger  of  a  glove,  and  had  a 
depth  of  9  cm.  and  a  circumference  of  6  cm.  The  mucous 
membrane  at  the  seat  of  the  stricture  was  quite  healthy. 
About  two-thirds  of  the  pouch  was  covered  with  muscle 
derived  from  the  inferior  constrictor. 

An  examination  of  pharyngeal  pouches  such  as  exist  in 
museums  would  lead  the  observer  to  believe  that  the  orifice 
of  communication  between  the  pharynx  and  the  pouch  was 
circular ;  but  there  is  good  reason  to  believe  that  it  assumes  a 
slit-like  form  even  when  the  pouch  is  full  of  food. 

So  far  as  our  knowledge  at  present  extends  in  regard  to 
this  variety  of  pharyngocele,  it  would  appear  that  such 
pouches  arise  in  all  probability  as  congenital  defects ;  but  it  is 
important  to  remember  that  they  rarely  cause  inconvenience 
until  late  in  life.  Thus,  Ludlow's  patient  was  60,  Worth- 
ington's  69,  Chavasse's  49,  and  Butlin's  47.  It  is  necessary 
to  point  out  that  a  pharyngocele  of  the  character  represented 
in  Fig.  325  arises  in  a  different  manner  from  that  depicted  in 
Fig.  246 ;  the  latter  is  probably  due  to  a  persistent  bronchial 
cleft. 

Treatment. — Pharyngoceles  are  likely  to  be  much  more 
carefully  studied  in  the  future  than  they  have  been  in  the 
past,  for  the  condition  has  on  more  than  one  occasion  been 


TRACHEAL  DIVERTICULA  615 

correctly  diagnosed,  and  the  pouch  removed  through  an 
incision  in  the  neck  and  its  slit-like  orifice  of  communica- 
tion with  the  pharynx  occluded  by  sutures — a  manoeuvre 
that  has  been  followed  by  complete  success  in  the  hands  of 
Bergmann,  Butlin,  and  others. 

(Esophageal  diverticula.  —  Hernial  protrusions  of  the 
mucous  membrane  of  the  oesophagus  through  the  muscular 
coat  are  not  common.  They  vary  greatly  in  size.  Some  are 
no  larger  than  cherries,  others  may  attain  the  size  of  a  closed 
fist.  Diverticula  arise  in  many  parts  of  the  oesojDhagus ; 
nothing  is  known  as  to  their  cause. 

Tracheal  diverticula. — These  are  small  hernial  protrusions 
of  the  mucous  membrane  of  the  trachea  ;  they  are  uncommon, 
and  invariably  occur  near  the  junction  of  the  trachealis  muscle 
with  the  cornua  of  the  semi-rings  of  the  trachea.  Rokitansky 
regarded  them  as  dependent  on  chronic  catarrh  of  the  trachea. 
Gruber,  on  the  other  hand,  was  of  opinion  that  they  are  re- 
tention-cysts of  the  glands  in  the  tracheal  mucous  membrane ; 
they  are  of  little  clinical  interest. 

The  tracheal  divertimdum  of  the  eimi. — The  emu  (DromcBus  novce- 
hollandice)  is  normally  provided  with  a  tracheal  diverticulum  of  great 
interest.  In  this  bird  there  is  a  natural  defect  in  the  front  of  the 
trachea,  at  a  spot  varying  between  the  fiftieth  and  sixty-fifth  ring.  The 
deficiency  may  involve  six  or  more  rings.  In  the  emu  chick  the  defect 
is  scarcely  noticeable,  and  the  extremities  of  the  rings  are  almost  in 
contact.  As  the  bird  grows  the  tracheal  mucous  membrane  becomes 
slowly  herniated  through  the  opening  until  it  forms  a  huge  sac  between 
the  skin  of  the  neck  and  the  trachea.  The  cyst- wall  is  composed  of 
connective  tissue  with  scattered  bundles  of  striated  muscle-fibre  ;  its 
mucous  lining  is  directly  continuous  with  that  of  the  windpipe,  and  is 
dotted  with  the  orifices  of  glands  (Fig.  326). 

The  adult  emu  inflates  this  sac  when  it  produces  the  peculiar  boom- 
ing sound  which  resembles  the  noise  made  by  blowing  across  the  mouth 
of  a  large  bottle. 

This  large  tracheal  sac  may  inflame  and  become  distended  with 
mucus.  In  a  specimen  which  I  secured  and  forwai-ded  for  preservation 
to  the  museum  of  the  Royal  College  of  Surgeons,  London,  the  sac 
contained  two  pints  of  mucus.  The  bird  was  unfortunately  droAvned  in 
this  fluid,  for  while  I  was  making  an  attempt  to  evacuate  the  contents 
of  the  sac  the  fluid  entered  the  opening  in  the  trachea  and  suffocated  it. 

Murie  has  written  an  excellent  account  of  the  anatomy  of  the  trachea 
of  the  emu.  I  can  confirm  his  observations,  having  enjoyed  oppor- 
tunities of  dissecting  the  adult  emu  and  the  emu  chick.  Concerning 
the  function  of  this  pouch  nothing  is  known. 


616 


PSEUI)0-GY8T8 


The  guttural  pouches  of  the  horse. — In  man  the  pharyngeal  orifice 
of  each  Eustachian  tube  opens  in  relation  with  a  bay  or  recess  termed 
the  fossa  of  Rosenmiiller.  In  the  horse  the  tubes  terminate  in  a 
very  different  manner.  When  the  head  is  removed  at  the  occipito- 
atlantal  articulation,  and  the  pharynx,  with  the  associated  structures, 
carefully  dissected  from  the  muscles  on  the  ventral  aspect  of  the  cer- 
vical region  of  the  spine,  it  will  be  found,  as  a  rule,  difficult  to  avoid 


Cul-de-sac. 


Wall  of  pouch 


Fig.  326. — Tracheal  oi^euing   and  pouch  of  an  emu.      The  pouch  is  cut  so  as  to 
expose  its  interior.     The  surrounding  feathers  are  cut  short.     {After  Murie.) 


cutting  into  two  large  sacs  separated  from  the  atlas  and  axis  by 
loose  connective  tissue.  They  reach  to  the  base  of  the  skull,  extend 
downwards  to  the  larynx,  and  send  processes  to  occujiy  the  intervals 
between  the  long  styloid  processes  and  the  mandible.  These  sacs  are 
the  guttural  pouches ;  they  abut  upon,  but  have  no  communication 
with,  each  other,  and  occupy  the  whole  of  the  naso-pharynx.  Each 
pouch  is  lined  with  delicate  mucous  membrane  containing  glands  and 
furnished  with  ciliated  epithelium. 


TEAGBEAL  DIVERTICULA 


617 


The  mucous  membrane  of  the  guttural  pouches  is  directly  con- 
tinuous with  that  lining  the  Eustachian  tubes.  The  pouches  them- 
selves appear  as  large  saccular  dilatations  of  the  terminal  ends  of 
the  tubes,  and  for  this  reason  they  are  termed  by  some  writers  the 
Eustachian  pouches.  Each  pouch  opens  into  the  pharynx  immediately 
above  the  soft  palate  by  a  valvular  orifice  ;  one  side  of  the  valve  is 
formed  by  the  leaf-like  termination  of  the  Eustachian  tube.  Of  the 
functions  of  these  pouches  nothing  is  known.  They  are  often  a  source 
of  inconvenience  to  horses,  for  the  mucous  membrane  is  very  prone  to 
become  inflamed,  and  the  scanty  outlet  for  the  secretion  leads  to  its 


Fig.  327. — Concretions  from  the  guttural  pouches  of  horses.     {Nat.  size. ) 


retention  and  the  consequent  dilatation  of  the  sacs.  When  enlarged  in 
this  way  they  may  have  a  capacity  of  six  or  more  ounces  each.  The 
retained  secretion  may  decompose,  and  the  sac  become  distended  with 
pus,  which  is  discharged  at  intervals  through  the  nose  ;  or  the  pharyn- 
geal orifice  may  be  occluded,  and  the  pouches  enlarge  to  such  an  extent 
as  to  require  an  incision  through  the  skin  of  the  neck  or  through  the 
mouth. 

Not  infrequently  the  contents  of  the  pouches  become  inspissated 
and  formed  into  concretions.  These  are  of  different  shapes  and  sizes, 
and  vary  in  number  from  one,  two,  or  three  to  fifty  or  even  more. 
Generally  they  are  of  an  oval  shape  ;  not  seldom  they  resemble  beans. 
In  consistence  these  concretions  are  like  cheese,  and  on  section  have  a 
laiuinated  appearance.  They  are  composed  of  mucus  and  inflammatory 
products  mixed  up  with  organic  particles  (Fig.  ,327). 

The  grit  in  these  concretions  enables  an  explanation  to  be  offered 
concerning  the  liability  of  the  pouches  to  attacks  of  inflammation.  As 
the  orifices  of  the  pouches  are  in  direct  communication  with  the  nasal 


618  PSEUD0-CT8T8 

passages,  dust  can  easily  enter  them  when  snuffed  up  with  fragments  of 
hay,  straw,  dried  seeds,  and  other  organic  and  inorganic  particles  from 
dusty  nose-bags  and  mangers. 

Laryngoceles. — In  certain  adult  monkeys,  particularly 
the  chimpanzee  {SimAa  troglodytes),  the  deep  cervical  fascia 
is  undermined  by  diverticula  from  the  laryngeal  mucous 
membrane.  This  large  subfascial  air-chamber  communi- 
cates with  the  larynx  through  the  thyro-hyoid  membrane ; 
it  extends  downwards  to  within  2  cm.  of  the  presternum. 
Exceptionally  it  dips  into  the  anterior  mediastinum,  and 
laterally  into  the  armpits,  the  axillary  fasciae  forming  the 
lowest  limits  of  the  sac. 

In  one  fine  chimpanzee  I  injected  this  huge  reservoir,  and 
found  it  would  hold  three  pints  of  injection  mass.  In  the 
howling  monkey,  Mycetes,  the  air-sac  is  very  large,  and  the 
basi-hyal  is  hollovred  to  form  a  resonance  chamber.  Cervical 
air-sacs  exist  in  many  mammals,  and  can  be  inflated  at  will. 
They  arise  as  diverticula  from  the  larynx,  either  from  the 
ventricle  or  from  the  pouch  of  Morgagni  in  the  middle  line 
of  the  larynx  below  the  epiglottis.  In  the  early  stages  the 
lateral  pouch  resembles  the  human  sacculus  laryngis  inflated. 
Gradually  the  sacs  undermine  the  deep  cervical  fascia  and 
subsequently  coalesce.  The  air-sac  of  the  adult  chimpanzee  is 
formed  by  fusion  of  two  lateral  pouches  and  a  niedian  pouch. 

There  is  great  variety  in  the  degree  of  development  of  the 
cervical  sacs  in  different  genera  and  species  of  mammals. 

In  1888  I  stated  the  following  reasons  for  regarding  some 
kinds  of  congenital  cervical  cysts  in  children  as  examples  of 
laryngeal  saccules : — 

The  congenital  nature  of  the  cysts.  Repetitions  of  animal 
structures  of  this  kind  are  always  congenital. 

Their  relation  to  the  hyoid  bone  and  larynx.  The  hollow 
of  the  basi-hyal  in  man  represents  the  large  cavity  in 
the  basi-hyal  of  many  mammals. 

The  situations  of  the  cysts  beneath  the  deep  cervical 
fascia  and  their  occasional  extension  into  the  axillse. 

von  Bergmann,  E.,  "  Ueber  den  OSsophagusdivertikel  und  seine  Behandlung." 

—Arch.f.  klin.  Chir.,  1892,  xliii.  1. 
Butlin,  H.  T.,  "On  the  Removal  of  a  '  Pressure-Fonch '  of  the  (Esophagus."  — 

Med.- Chir.  Trans.,  1893,  Ixxvi.  269. 


REFEBENGE8  619 

Chavasse,  T.  F.,  "  On  a  Case  of  Pressure  Diverticulum  Ox  the  CEsophagus." 

Trans.  Path.  Soc,  1891,  xlii.  82. 
von    Kostanecki,  "  Zur    Kenntniss  der  Pliarynxdivertikel  des  Menschen   mit 

besonderer  Berucksichtigung  der  Divertikelbildungen  und  Nasenrachen- 

raum." — Virchow's  Arclt.f.patli.  Anat.,  1889,  cxvii.  108. 
Lane,  W.  A.,  "  The  Pathology  of  Extravasation  of  Urine  and  of  Sacculation  of 

the  Urethra  and  Bladder." — Giu/s  Hasp.  Mepis.,  1885-86,  xliii.  29. 
Ludlow,  "A  Case  of  Obstructed  Deglutition  from  a  Preternatural  Dilatation  of 

the  Bag  formed  in  the  Pharynx." — Medical  Observation.'^  and  Inquiries, 

1769,  iii.  85,  pi.  v. 
Shattock,  S.  G.,  "  Congenital  Atresia  of  the  ffisophagus."— 2Va?is.  Path.  Soc. 

1890,  xli.  87. 

White,  W.  Hale,   "A  Sacculated  Bladder  in  a  Female."' — Trans.  Path.  Soc, 

1883,  xxxiv.  146. 
Worthington,  W.  C,  "A  Case  in  which  a  large  Pouch  was  formed  in  the 

(Esophagus  in  connection  with  Contraction  of  the  Canal." — Med.-Chir. 

Trans.,  1847,  xxx.  199. 


CHAPTER    LX 

PSEUDO-CYSTS  (Continued) 
STNOyiA.L   CYST,  GANGLION,  AND  BUaSA 

Synovial  cysts.  —  Cysts   containing   synovia   arise   in    three 

ways : — 

1.  Hernial  protrusions  ot   the  synovial   membranes  of 

j  oints. 

2.  Burste  in  the  immediate  neighbourhood  of  joints. 

3.  Hernial    protrusions    of    the    s3^novial    sheaths    of 

tendons. 

Synovial  cysts  arise  in  connexion  with  the  hip,  knee, 
ankle,  shoulder,  elbow,  and  wrist  joints.  They  have  been 
most  carefully  studied  in  connexion  with  the  knee-joint.  The 
cysts  form  swellings,  in  some  cases  as  large  as  an  orange, 
situated  near  the  knee-joint,  usually  in  close  relation  with  the 
tendons  of  the  semimembranosus,  biceps,  or  gastrocnemius 
muscle.  Occasionally  the  cyst  will  be  situated  in  the  calf  on 
the  inner  side,  sometimes  as  much  as  8  cm.  below  the  knee. 
When  the  swelling  is  situated  near  the  joint,  pressure  will 
cause  it  to  disappear,  the  synovia  it  contains  passing  into  the 
general  cavity  of  the  joint.  When  the  cyst  is  situated  at  a 
distance  from  the  joint,  pressure  upon  it  may  have  no  effect  in 
diminishing  its  size,  because  in  many  cases  the  communica- 
tion between  the  cyst  and  the  joint-cavity  is  by  a  very 
narrow,  almost  capillary  channel. 

The  cysts  arise  usually  in  connexion  with  joints  which  are 
chronically  diseased,  and  seem  to  be  common  in  tuberculous 
joints.  It  is  believed  by  those  who  have  devoted  special 
attention  to  these  cysts  that  when  the  joints  become  distended 
with  synovia  the  internal  pressure  causes  the  synovial  mem- 
brane to  protrude  through  weak  spots  in  the  capsule,  the 
diverticula  making  their  way  along  the  intermuscular  planes. 

620 


SYNOVIAL  CYSTS 


621 


This  mode  of  origin  is  similar  to  that  which  obtains  in  the 
case  of  sacculated  bladders. 

It   is   also   certain,  for  it  has  been  demonstrated  by  dis- 


Opening  of  bursa  into  tlie  joint. 


Bursa, 


Remains  of  a  previous  cyst. 


Fig.  328. — Bursa  under  the  semimembranosus  tendon  commuaicating  with  the 
knee-joint.  A  cyst  had  been  incised  and  drained  sixteen  months  previously; 
its  partially  obHterated  channel  persists.     {B'Jrcy  Power.) 

section,  that  some  synovial  cysts  are  due  to  bursas  normally 
existing  under  the  adjacent  tendons  becoming  abnormally 
large  and  communicating  with  the  joint-cavity  in  consequence 
of  absorption  of  the  contiguous  parts  of  the  wall  by  pressure 
(Fig.  328),    This  seems  to  happen  most  frequently  in  the  case 


622  PSEUD0-GY8TS 

of  the  bursa  under  the  semimembranosus.  It  does  not 
necessarily  follow,  because  an  individual  has  a  synovial  cyst 
near  the  knee,  that  the  joint  is  diseased ;  attendance  in  an 
out-patient  room  will  show  that  many  synovial  cysts  slowly 
disappear  without  treatment.  This  is  important  to  bear  in 
mind,  for  interference  with  these  cysts  is,  as  a  rule,  needless 
and  often  productive  of  much  harm.  Aspiration,  injection  of 
iodine,  and  the  insertion  of  setons  may  lead  to  suppuration, 
and  destruction  of  the  joint  with  which  the  cyst  is  connected. 
Morrant  Baker,  who  first  drew  special  attention  to  these 
synovial  diverticula,  states  that  when  they  arise  in  connexion 
with  the  knee  the  cyst  will  project  in  the  popliteal  space,  the 
upper  part  of  the  calf,  or  on  the  inner  side  of  the  calf  as  much 
as  10  cm.  below  the  head  of  the  tibia. 

In  the  case  of  the  shoulder,  the  cyst  projects  in  front  of 
the  joint  a  little  below  the  clavicle,  or  in  the  upper  third  of 
the  arm  in  the  course  of  the  long  tendon  of  the  biceps. 

In  the  case  of  the  elbow,  the  cyst  projects  on  the  inner 
side  of  the  arm  above  the  condyle.  I  have  seen  a  cyst  of 
this  kind  as  high  as  the  insertion  of  the  coraco-brachialis, 
connected  with  the  elbow-joint  by  a  tubular  process  of  the 
diameter  of  the  anterior  interosseous  arterj^.  When  they 
arise  from  the  carpal  joints,  the  cysts  project  on  the  back  or 
front  of  the  wrist.  (See  under  Ganglion.)  When  connected 
with  the  hip-joint,  the  cyst  forms  a  swelling  in  Scarpa's  space ; 
and  in  the  case  of  the  ankle,  the  bulging  is  most  marked  in 
front  and  to  the  outer  side  of  the  joint. 

The  fluid  contained  in  synovial  cj/sts  is  in  most  cases 
identical  with  synovia,  and  occasionally  contains  "  melon- 
seed"  bodies.  When  the  joint  is  tuberculous  the  fluid  in 
the  cyst  will  be  purulent ;  when  the  skin  over  these  swell- 
ings is  red  and  glossy  they  have  been  mistaken  for  simple 
abscesses  and  incised. 

Ganglion. — A  ganglion  is  a  cyst  formed  by  the  hernial 
protrusion  of  the  synovial  lining  of  a  tendon-sheath.  There 
are  two  species — simple  and  compound. 

A  simple  ganglion  is  seen  in  its  most  typical  condition 
on  the  back  of  the  carpus,  where  it  forms  a  rounded  sessile 
elastic  swelling  which  becomes  tense  when  the  wrist  is  flexed, 
and  partially,  or  wholly,  disappears  when  the  wrist   is   ex- 


GANGLIA  623 

tended.  Many  of  these  swellings,  which,  are  entered  in 
clinical  records  as  ganglions  (or  ganglia),  are  not  connected 
with  tendon-sheaths.  I  have  satisfied  myself  by  careful  dis- 
sections that  many  of  them  are  diverticula  from  the  carpal 
joints,  and  in  some  instances  they  arise  from  the  inferior 
radio-ulnar  joint.  As  in  the  case  of  the  larger  joints, 
synovial  cysts  arising  from  the  carpus  are  occasionally 
associated  with  tuberculous  arthritis. 

Ganglia  are  sometimes  met  with  on  the  fingers  in  con- 
nexion with  the  sheaths  of  the  long  flexors  and  on  the 
dorsum  of  the  foot ;  as  well  as  on  the  outer  side  of  the  ankle 
in  relation  with  the  tendons  of  the  peroneus  longus  and 
brevis.  The  fluid  in  a  simple  ganglion  is  clear,  transparent, 
and  viscid,  resembling  apple  jelly. 

The  compound  ganglion  is  a  much  more  serious  con- 
dition. It  occurs  mainly  at  the  wrist  in  connexion  with  the 
flexor  and  extensor  tendons ;  it  also  occurs  occasionally  on 
the  tendons  of  the  peroneal  muscles,  where  they  lie  in  relation 
with  the  calcaneum. 

A  compound  ganglion  at  the  wrist  assumes  an  irregular 
shape  and  extends  for  a  variable  distance  up  the  forearm ;  it 
also  sends  a  prolongation  under  the  annular  ligament  to 
appear  in  the  palm,  when  it  arises  in  connexion  with  the 
flexor  tendons  ;  a  similar  extension  under  the  posterior  annu- 
lar ligaments  is  usually  noticed  when  a  ganglion  is  connected 
with  the  extensor  tendons.  A  compound  ganglion  is  usually 
soft  and  elastic,  and  imparts  a  crepitant  sensation  to  the 
examining  fingers  when  the  tendons  are  set  in  action.  This 
crepitant  sensation  is  due  to  the  presence  in  the  ganglion  of 
small  bodies  familiarly  known  as  melon-seed  bodies,  from 
their  shape  and  consistence ;  these  are  sometimes  present  in 
enormous  numbers.  There  is  much  difference  of  opinion 
as  to  the  source  of  these  bodies ;  often,  in  the  course  of  an 
operation,  they  may  be  seen  hanging  from  the  inner  wall  of 
the  ganglion.  An  examination  of  many  of  the  loose  bodies 
will  show  that  they  have  slender  stalks ;  these  appear  more 
clearly  when  they  are  placed  in  water.  Bodies  identical  in 
structure  are  met  with  in  synovial  diverticula  and  even  in 
bursal  sacs,  particularly  the  prepatellar  bursa. 

Treatment. — A  simple  ganglion,  such  as  is  so  common  on 


624  P8EUD0-GYSTS 

the  back  of  the  wrist,  is  in  a  general  way  successfully  treated 
by  bursting  it  subcutaneously  b}''  the  direct  pressure  of  the 
thumb,  and  then  applying  a  graduated  compress  for  a  few 
days.  When  the  wall  is  so  thick  that  it  will  not  rupture,  the 
swelling  may  be  punctured  with  a  very  narrow  scalpel ;  this 
allows  the  mucoid  contents  to  escape,  and  the  application  of  a 
firm  compress  for  a  few  days  will  obliterate  the  sac. 

A  compound  ganglion  should  be  dissected  out  as  if  it 
were  a  tumour,  and  it  would  appear  that  the  patient  runs 
less  risk  from  this  mode  of  treatment  than  by  the  common 
practice  of  incision  and  drainage. 

It  is  well  to  bear  in  mind  that  some  of  these  ganglia  are 
associated  with  the  early  stages  of  tuberculous  disease  of  the 
wrist-joint,  and  a  few  are  undoubtedly  due  to  tuberculous 
infection  of  the  tendon-sheaths. 

Bursse. — On  many  parts  of  our  bodies  where  muscles  and 
tendons  glide  over  osseous  surfaces,  or  in  situations  where 
skin  lies  in  close  contact  with  bony  prominences,  membran- 
ous sacs  occur  filled  with  glairy  fluid;  such  sacs  are  known 
as  bursse.  Structurally  a  bursa  consists  of  a  thin-walled  sac 
filled  with  glair}^  fluid.  The  inner  wall  of  the  cyst  is  quite 
smooth  and,  as  a  rule,  devoid  of  epithelium. 

In  certain  situations,  such  as  the  anterior  surface  of  the 
patella  and  the  posterior  surface  of  the  olecranon,  a  bursa  is 
normally  present.  Bursal  sacs  may  form  in  any  part  of  the 
subcutaneous  tissues  when  the  overlying  skin  is  submitted 
to  friction  and  intermittent  pressure,  as  in  talipes  when  the 
patient  walks  on  the  dorsum  or  side  of  the  foot;  beneath 
corns;  and  at  the  metatarso-phalangeal  joint  in  the  condition 
termed  bunion.  Such  are  called  adventitious  burssB.  When 
burste  arise  in  connexion  with  tendons,  they  are  spoken  of 
as  subtendinous -bursse,  and  they  often  communicate  Avith  the 
sheath  of  the  tendon,  and  even  with  an  adjacent  joint.  The 
large  bursa  so  constantly  present  at  the  insertion  of  the  semi- 
membranosus often  has  a  direct  communication  with  the  joint. 

The  origin  of  bursal  sacs  has  been  explained  in  the  follow- 
ing manner : — 

When  the  skin  moves  over  joints  or  hard  prominences 
the  intermediate  connective  tissue  becomes  torn  or  ruptured, 
thereby  leading   to  the  formation   of  spaces  in  which  fluid 


BURSAL  6'25 

collects.  The  boundary  walls  are  at  first  irregular,  and  are 
formed  by  adjacent  connective  tissue.  Finally  this  becomes 
smooth  and  forms  the  sac-wall. 

Bursse  may  arise  during  intra-uterine  life  when  the  foetus 
is  submitted  to  abnormal  pressure.  Many  remarkable  in- 
stances of  this  have  been  recorded,  especially  in  association 
with  talipes. 

Most  subcutaneous  and  many  subtendinous  bursEe  arise 
after  birth.  Bursae  often  attain  an  abnormal  size  in  con- 
sequence of  pressure  associated  with  particular  occupations. 
For  instance,  too  much  kneeling  on  hard  material,  whether 
by  housemaids,  devout  persons,  or  carpet-layers,  produces  the 
familiar  prepatellar  bursa ;  repeated  blows  on  the  elbow  pro- 
duce miner's  elbow ;  from  carrying  weights  on  the  shoulder 
porters  are  liable  to  get  a  bursa  over  the  acromial  end  of  the 
clavicle ;  tailors  from  their  cross-legged  habit  of  sitting  are 
sometimes  troubled  with  one  over  the  external  malleolus  ; 
whilst  weavers  and  lightermen  from  prolonged  sitting  on 
hard  seats  suffer  from  bursas  over  their  ischial  tuberosities : 
soldiers  when  sleeping  too  frequently  on  the  hard  floor  of  the 
guard-room  get  them  over  their  greater  trochanters ;  the 
pressure  of  ill-fitting  boots  develops  a  bursa  over  the  enlarged 
head  of  the  metatarsal  bone  of  the  hallux — when  associated 
with  partial  dislocation  of  the  first  phalanx  it  is  known  as  a 
bunion ;  and  bursse  are  quite  common  on  the  ends  of  ampu- 
tation-stumps, and  in  relation  with  exostoses.  Clement 
Lucas  has  described  as  the  needlewoman's  bursa  a  cyst  that 
formed  on  the  palmar  surface  of  the  terminal  phalanx  of  the 
middle  finger  in  an  old  seamstress.  A  bursa  is  often  present 
between  the  body  of  the  hyoid  bone  and  the  thyro-hyoid 
membrane;  and  jockeys  acquire  one  in  front  of  the  ankle 
from  the  pressure  of  the  stirrup. 

Bursas  are  liable  to  intiame,  a  process  that  may  lead  to 
suppuration,  or  stop  short  of  that  condition  and  become 
chronic  or  recurrent  and  lead  to  secondary  changes  in  the 
walls  of  the  sac  so  that  its  cavity  becomes  almost  obliter- 
ated. Chronically  inflamed  bursse  may  attain  the  size  of 
fists,  especially  the  prepatellar  and  ischial  varieties.  Pre- 
patellar bursas  sometimes  rapidly  solidify  in  syphilitics. 

Jephson,  in  his  interesting  account  of  "  Emin  Pasha  and 
2  o 


626 


PSEUDO-CYSTS 


the  Rebellion  at  the  Equator,"  relates  that  the  woraen  and 
many  men  of  the  Bari  tribe  whom  he  saw  working  in  the 
fields  had  enlarged  prepatellar  burste  due  to  kneeling  whilst 
at  work,  and  to  the  fact  that  the  entrances  to  their  huts  were 
so  low  that  it  was  necessary  to  enter  on  the  hands  and  knees. 


r-r/^o/^hjh 


Fig.  329. — Gravid  Fallopian  tube  with  a  pseudo-cyst  or  capsule  formed  around 
the  blood  effused  through  the  ccelomic  ostium,  b  shows  the  capsule  entire, 
and  in  a  it  is  in  section  so  as  to  display  its  relation  to  the  ostium  and  fimbriae,*. 

Treatment. — An  inflamed  bursa  demands  rest  and  the 
local  treatment  usually  employed  for  inflamed  parts.  When 
the  bursa  is  distended  with  fluid,  it  is  the  custom  to  apply  a 
plaster  of  mercury  and  ammoniacum  over  the  swelling  and 
fix  it  firmly  with  a  bandage.  It  is  probable  that  the  firm 
compression  is  the  chief  agent  in  promoting  the  absorption  of 


\BVB8^  627 

the  fluid.  In  some  cases  the  swelling  subsides  spontaneously, 
and  this  probably  explains  the  supposed  efficacy  of  the  appli- 
cation of  tincture  of  iodine. 

When  burs£e  are  repeatedly  irritated,  the  walls  become  so 
thick  that  the  tumour  has  to  be  excised.  This  mode  of  treat- 
ment is  necessary  when  a  bursa  contains  loose  bodies.  When 
the  bursa  is  situated  over  the  patella,  malleolus,  ischial 
tuberosity,  or  trochanter  its  removal  is  a  very  simple  pro- 
ceeding. 

When  a  bunion  inflames  and  suppurates  it  may  involve 
the  underlying  metatarso-phalangeal  joint.  Many  of  these 
cases,  especially  in  elderly  individuals,  demand  amputation  of 
the  toe.  When  it  is  necessary  to  carry  out  this  measure,  it  is 
much  more  satisfactory  to  remove  the  metatarsal  bone  as  well 
as  the  toe. 

Pseudo-cysts  in  connexion  with  the  Fallopian  tube. 
— When  from  any  cause  a  clean  foreign  body  finds  its  way 
into  the  peritoneal  cavity,  or  a  sterile  coagulable  fluid  is 
exuded  therein,  a  process  is  established  whereby  the  foreign 
substance  is  encysted.  Shattock  once  found  a  rounded  body 
with  a  diameter  of  6"25  cm.  in  the  pelvis  of  a  man,  between  the 
rectum  and  bladder.  On  section  a  piece  of  iron  was  detected 
in  its  centre,  surrounded  by  regular  laminse  of  structureless 
material.  He  regarded  this  as  an  instance  in  which  a  piece 
of  metal  taken  into  the  alimentary  canal  had  entered  the 
peritoneal  cavity  by  traversing  the  wail  of  the  intestine  ;  it 
had  then  become  encysted  by  exudation  (lymph)  from  the 
peritoneum. 

It  happens  very  frequently  in  cases  of  tubal  pregnancy 
which  terminate  by  what  is  known  as  tubal  abortion,  and 
especially  the  form  known  as  incomplete  tubal  abortion  in 
which  blood  slowly  trickles,  or  even  drips,  from  the  coelomic 
ostium,  that  the  effused  blood  becomes  surrounded  by  a 
lowly  organized  capsule,  and  this  is  occasionally  so  complete 
as  to  appear  like  an  ovoid  bulb  or  amphora  containing  blood, 
and  its  neck  embracing  the  coelomic  ostium  of  the  tube 
(Fig.  329). 

This  condition,  and  the  mode  of  formation  of  the  cap- 
sules, have  been  particularly  studied  by  Saenger,  Taylor, 
and   Handley.     The  last  observer  has   proved  that  capsules 


628 


PSEUDO-CYSTS 


of  this  kind  are  also  formed  occasionally  in  connexion 
with  tubal  pregnancy  terminating  by  rupture.  Capsules  of 
this  nature  occasionally  form  around  sterile  inflammatory 
effusions  (Fig.  330). 

It  would  appear  that  the  conditions  necessary  to  the 
production  of  these  capsules  are  these :  the  intruded  product 
■ — whether  a  solid  body,  an  infusion  of  blood,  or  coagulable 
inflammatory  fluid — should  be  free  from  pathogenic  organ- 
isms, and,  in  the  case  of  fluid,  be  slowly  effused. 

In  this  way  imperfect  capsules  are  formed  on  the  walls  of 
ovarian   cysts,  especially  dermoids,  and  there  can   be   little 


Fie 


330. — Fallopian  tube  and  ovary  ;  the  ccelomic  ostium  and  fimbriee  are  enclosed 
in  a  capsule  of  new  formation.     From  a  case  of  acute  salpingitis. 


doubt  that  many  of  the  reported  cases  in  which  these  cysts 
are  stated  to  have  burrowed  between  the  layers  of  the  broad 
ligaments  rest  on  erroneous  observation,  and  that  the  supposed 
investment  by  the  mesometrium  was  in  reality  a  capsule  of 
new  formation. 

The  most  perfect  capsules  formed  in  this  Avay  are  met  with 
around  echinococcus  cysts  in  the  belly,  especially  those  which 
project  from  the  under-surface  of  the  liver,  or  grow  in  the 
meshes  of  the  omentum,  and  on  occasions  they  may  be  very 
thick.  This  explains  how  echinococcus  colonies  in  the  belly 
are  provided  with  thick  spurious  capsules,  whereas  those 
growing  in  the  cerebrum  have  none. 


CHAPTER   LXI 
PSEUDO  -  CYSTS    (Continued) 

NEURAL  CYSTS 

Under  this  heading  it  is  proposed  to  consider  a  number  of 
conditions,  some  of  which,  like  hydrocephalus  and  one  variety 
of  spina  bifida,  should  be  described  with  tubulo-cysts.  Other 
varieties  of  spina  bifida  should  be  discussed  with  diverticula. 
On  the  whole  it  is  more  convenient  to  consider  them  collec- 
tively as  neural  cysts. 

Hydrocephalus. — This  term  is  applied  to  the  head  when 
abnormally  enlarged  in  consequence  of  excessive  accumula- 
tion of  fluid  in  the  ventricles  of  the  brain.  A  very  large 
majority  of  cases  are  congenital,  or  commence  in  the  early 
months  of  infancy.  Occasionally  the  condition  will  arise  at  a 
later  period  of  life,  when  the  fontanelles  are  obliterated  ; 
expansion  of  the  skull  is  then  impossible.  Hydrocephalus 
very  frequently  accompanies  spina  bifida.  Yery  many  hydro- 
cephalic foetuses  die  during  delivery,  the  large  size  of  the  head 
hindering  its  successful  transit  through  the  maternal  passages. 
In  some  cases  the  head  ruptures  in  consequence  of  the  pres- 
sure to  which  it  is  subjected,  or  it  is  intentionally  perforated. 
In  many  cases  of  hydrocephalus  which  survive  delivery,  the 
distension  is  only  slight  at  birth. 

The  frequency  with  which  hydrocephalus  and  hydramnion 
co-exist  w(  uld  indicate  that  the  association  is  something  more 
than  mere  coincidence.  Statistics  respecting  the  frequency  of 
hydrocephalus  drawn  from  living  children  are  untrustworthy, 
as  prenata)  hydrocephalus  is  very  fatal. 

In  typical  cases  of  hydrocephalus  attention  is  arrested  by 
the  large  size  of  the  cranium  and  the  smallness  of  the  face. 
This  is  due  to  the  slow  accumulation  of  fluid  within  the 
cerebral  ventricles  distending  them  and  causing  wide  separa- 
tion of  the  cranial  bones,  whilst  the  bones  of  the  face  retain 

629 


630 


P8EUD0-CY8TS 


their  natural  proportions.  The  two  halves  of  the  frontal  bone 
are  separated  from  each  other ;  the  spaces  between  the 
parietal  bones,  and  between  these  and  the  occipital,  are  far 
wider  than  usual  (Fig.  331).  Indeed,  the  bones  of  the  cranial 
vault  are  so  separated  from  each  other,  whilst  those  of  the 
base  retain  their  usual  juxtaposition,  that  the  bones  of  a 
hydrocephalic  skull  were  compared  by  Trousseau  to  the  petals 
of  an  opening  flower. 


331. — Skull  of  an  infant  the  subject  of  hydioceplialus. 
{Museum,  Middlesex  Hospital.) 

The  head  may  become  so  large  as  to  attain  a  circumference 
of  a  metre,  or  even  a  metre  and  a  half  when  measured  hori- 
zontally— that  is,  from  the  superciliary  ridges  to  the  inion 
The  bones  are  excessively  thin,  and  consist  of  a  single  table. 
The  vault  presents  large  membranous  spaces  irregularly 
dotted  with  ossific  deposits.  The  sutures  in  relation  with  the 
parietal  bones  are  occupied  with  Wormian  bones ;  as  many  as 
two  hundred  have  been  counted  in  one  skull  (Fig.  332).  In 
hydrocephalics  who  attain  adult  life  the  skull  may  become 
completely  covered  in  with  bone. 

The  brain  presents  great  changes.  The  lateral  ventricles 
are  widely  distended,  and  the  crura  cerebri,  corpora  striata, 


EYDBOGEPHAL  US 


631 


optic  tlialami,  and  other  structures  in  the  base  of  the  brain 
are  flattened.  The  cerebral  hemispheres  form  thin  boundaries 
to  the  ventricles,  often  less  than  10  mm.  in  thickness ;  the 
convokitions  become  obhterated.  In  nearly  all  the  speci- 
mens the  distension  is  limited  to  the  lateral  and  third  ven- 
tricles ;  occasionally  the  fourth  ventricle  also  is  distended 
(Fig.  333).    In  some  specimens  each  lateral  ventricle  has  been 


Fig.   332.— Skull  of  an  adult  the  subject  of  hydrocephalus. 

{Museum.,  Middlesex  Hospital.) 

known  to  attain  a  length  of  20  cm.  and  to  communicate  with 
its  fellow  through  an  opening  three  inches  wide. 

When  the  ventricles  are  very  distended  and  the  skull 
is  proportionally  thin,  a  wave  of  fluctuation  may  be  trans- 
mitted from  side  to  side.  In  exceptional  cases  the  head  is 
translucent. 

In  an  account  of  hydrocephalus  it  is  difficult  to  avoid 
reference  to  the  classical  case  of  James  Cardinal,  especially  as 
a  cast  of  his  head  is  to  be  found  in  many  pathological 
museums  (Fig.  334). 

James   Cardinal  died   at  the   age   of  29  years   in   Guy's 


632 


P8EUD0-C'Y8T8 


Hospital,  under  the  care  of  Sir  Astley  Cooper,  in  1824.  He 
was  born  at  Coggeshall,  Essex,  in  1795.  At  birth  his  head 
was  very  little  larger  than  natural.  A  fortnight  later  it 
began  to  increase,  and  gradually  grew  until  he  was  five  years 
old,  and  then  appeared  to  remain  stationary.  He  was  unable 
to  walk  until  6  years  of  age,  but  went  to  school  and  learned 
to  read  and  write.     His  head  was  at  this  period  translucent 


Fig.  333. — Sagittal  section  of  a  child's  head  the  subject  of  hydrocephalus,  with  the 
brain  in  situ.  The  head  of  the  arrow  is  in  the  fourth  and  its  feathers  in  the  third 
ventricle.     The  iufundibulum  is  widely  dilated.     (JlKseiim,  Middlesex  Hospital.) 

when  placed  between  the  eye  of  the  observer  and  a  bright 
light.  Cardinal  continued  in  tolerable  health  until  23  years 
of  age,  when  he  began  to  have  fits,  for  which  he  applied 
to  the  hospital.  His  manners  were  childish,  otherwise 
his  mental  faculties  were  well  developed.  Death  eventually 
supervened  from  lung  disease. 

When  the  head  was  examined  the  brain  was  found  lying 
at  the  base  of  the  skull.     Between  the  membranes  there  were 


HYDROCEPHALUS 


633 


seven  pints  of  fluid.  The  ventricles  contained,  one  pint.  It 
appeared  as  if  the  fluid  had  been  originally  contained  within 
the  ventricles,  but  had  burst  through  an  opening  in  the 
corpus  callosum  and  compressed  the  brain  downwards.  The 
cranium  measured  82'5  cm.  (33  inches)  in  circumference,  and 
had  a  capacity  of  ten  pints.  The  skeleton  is  contained  in 
Guy's  Hospital  Museum. 

The  fluid  in  hydrocephalus  is  identical  with  cerebro-spinal 


Fig.  334. — Drawing  from   a  cast  of  the  head  of  James  Cardinal.     The  cast  from 
which  this  drawing  was  taken  appears  to  have  been  moulded  April  11th,  1822. 

fluid.  Occasionally  it  has  been  found  to  contain  albumin. 
This  may  be  attributed  to  inflammation,  and  has  been  observed 
in  those  cases  where  paracentesis  has  been  performed.  The 
amount  of  fluid  may  be  very  large.  Six  and  eight  and  even 
ten  pints  have  been  recorded.  Little  is  known  as  to  the 
cause  of  hydrocephalus.  In  many  cases  obstruction  to  the 
interventricular  communications  has  been  detected.  Hydro- 
cephalus is  often  associated  with  spina  bifida,  and  all  the 
passages  in  the  brain  and  the  central  canal  of  the  cord  have 
been  found  dilated. 


634  PSEUDO-CYSTS 

The  great  difficulty  encountered  in  investigating  the 
pathology  of  this  condition  arises  from  the  soft  and  diffluent 
nature  of  the  brain  of  hydrocephalic  foetuses,  especially  when 
stillborn.  It  should  also  be  remembered  that  many  gross 
malformations  of  the  limbs  and  viscera  are  often  associated 
with  hydrocephalus,  and  it  is  well  to  bear  in  mind  the  fre- 
quency with  which  it  is  accompanied  by  hydramnion. 

Hydrocele  of  the  fourth  ventricle. — ^Leading  from  each 
lateral  angle  of  the  fourth  cerebral  ventricle  there  is  a  tubular 
process  encircled  by  a  duplicature  of  the  ligula  termed  the 
cornucopia.  These  passages  or  lateral  recesses  are  traversed 
by  the  choroid  plexuses  of  the  fourth  ventricle,  and  the  re- 
cesses themselves  open  into  the  subarachnoid  space  at  the 
base  of  the  flocculus,  close  beside  the  root-filaments  of  the 
facial,  auditory,  glosso-pharyngeal,  and  vagus  nerves.  These 
passages  establish  free  communication  between  the  fourth 
ventricle  and  the  general  subarachnoid  space.  When  one  of 
these  processes  becomes  occluded,  the  recess  will  dilate  and 
form  what  Virchow  terms  hydrocele  of  the  fourth  ventricle. 
This  pathologist  has  figured  a  specimen  that  had  attained 
the  size  of  a  cherry-stone  ;  it  pressed  upon  the  flocculus 
and  the  facial  nerve ;  remnants  of  the  choroid  plexus  of  the 
fourth  ventricle  projected  into  the  cyst.  Though  the  walls  of 
this  cyst  were  thin,  its  pressure  had  caused  paralysis  of  the 
facial  nerve. 

Cranial  meningocele. — This  term  is  applied  to  a  hernial 
protrusion  of  the  meninges  of  the  brain  through  an  unossified 
portion  of  the  skull.  When  the  protrusion  consists  of  brain- 
matter  as  well  as  membranes  it  is  described  as  a  meningo- 
encephalocele. 

Meningoceles,  using  the  term  in  its  general  sense,  occur 
in  definite  regions.  The  commonest  of  all  situations  is  the 
occiput ;  in  about  two-thirds  of  the  cases  the  tumour  projects 
in  this  part  of  the  skull.  Next  in  frequency  to  their  appear- 
ance at  the  occiput,  meningoceles  appear  at  the  root  of  the 
nose.  In  other  regions  of  the  skull  they  are  excessively  rare. 
It  is  usually  stated  that  they  may  appear  at  the  anterior 
fontanelle,  but  critical  examination  of  the  descriptions  of  sus- 
pected cases  makes  it  probable  that  many  of  the  supposed 
meningoceles  were  dermoids  (p.  460). 


CRANIAL  MENINGOCELE 


635 


Occipital  meningoceles  appear,  during  life,  to  protrude 
through  the  foramen  magnum  ;  when  the  parts  are  dissected 
the  pedicle  will  be  found  to  make  its  way  through  a  gap  in 
the  supra-occipital  between  the  posterior  margin  of  the  fora- 
men magnum  and  the  occipital  protuberance.  This  space 
during  early  embryonic  life  is  occupied  by  a  fontanelle. 

The  relations  of  the  flocculus  in  cases  of  occipital  meningo- 
cele are  of  importance.  In  the  descriptions  of  reported  cases 
of  this  malformation  the  cerebellum,  if  referred  to,  is  described 
as  rudimentary  or  absent.  As  a  matter  of  fact,  in  these  cases 
the  cerebellum  is  absent,  and  that  which  is  supposed  to 
represent  this  part  of  the  brain  is  an  enlarged  flocculus  (Fig. 


Flocculus. 
Fig.  335. — Occipital  meningo-encephalocele.     The  cyst  probably  represents  an  ex- 
panded fourth  ventricle  :  there  was  no  cerebellum,  but  a  large  and  conspicuous 
flocculus. 

335).  Cleland  has  pointed  out  that  the  flocculus  is  developed 
from  a  lateral  outgrowth  of  the  floor  of  the  third  encephalic 
vesicle,  whilst  the  cerebellum  is  developed  from  the  foremost 
part  of  the  roof  of  that  vesicle.  An  appreciation  of  this  fact 
throws  valuable  light  on  the  nature  of  occipital  meningocele, 
for  the  absence  of  the  cerebellum  indicates  that  the  hernial 
protrusion  is  the  third  encephalic  vesicle ;  instead  of  its 
walls  thickening  to  form  a  cerebellum,  they  become  pas- 
sively dilated  into  a  cyst.  Indeed,  this  form  of  meningocele 
bears  much  the  same  relation  to  the  fourth  ventricle  and 
the  cerebellum  that  hydrocephalus  bears  to  the  lateral 
ventricles  and  the  cerebrum.  An  occipital  meningocele 
might  not  inaptly  be  described  as  hydrocephalus  limited 
to  the  fourth  ventricle. 


636  PSEUDO-CYSTS 

Occipital  meningo-encephaloceles  often  hang  so  low  as  to 
render  it  difficult  to  decide  whether  the  cyst  belongs  to  the 
cranium  or  to  the  cervical  region  of  the  spine.  There  is 
reason  to  believe  that  the  pedicle  of  a  cranial  meningocele 
may  become  obliterated  so  as  to  cut  off  the  communication 
between  the  cyst  and  the  subdural  space.  I  have  never  had 
an  opportunity  of  dissecting  a  specimen  in  which  this  has 
happened.  Such  an  event  certainly  occurs  with  spinal 
meningoceles. 

A  cranial  meningocele  is  sometimes  associated  with  spina 
bifida ;  such  a  combination  is,  as  a  rule,  accompanied  by  gross 
malformations,  especially  in  connexion  with  the  lower  limbs. 
It  has  already  been  mentioned  that  dermoids  are  apt  to  be 
mistaken  for  meningoceles,  and  it  is  certain  that  meningoceles 
are  sometimes  mistaken  for  dermoids.  With  careful  aseptic 
precautions,  meningoceles  may  be,  and  often  are,  safely 
excised.  In  some  cases  treated  in  this  way  hydrocephalus 
has  supervened. 

Infants  with  meningoceles,  especially  when  the  cyst  is 
large,  rarely  survive  their  birth  many  weeks  ;  death  is  usually 
due  to  sloughing  of  the  sac  and  septic  meningitis. 

The  cerebro-spinal  fluid. — Hydrocephalus  and  meningo- 
cele are  due  to  an  excessive  accumulation  of  this  fluid, 
which  has  physical  and  chemical  properties  that  dis- 
tinguish it  from  any  other  secretion  in  the  body.  Under 
normal  conditions  it  is  clear  like  water,  with  a  specific 
gravity  of  1006  to  1008,  and  devoid  of  all  corpuscular  ele- 
ments ;  it  contains  a  small  amount  of  protein  matter.  Its 
principal  constituent  is  sodium  chloride  ;  it  also  contains  traces 
of  carbonates,  bicarbonates,  phosphates,  urea,  and  dextrose. 
The  presence  of  sugar  (dextrose)  was  detected  by  Claude 
Bernard  (1858),  and  this  observation  is  confirmed  by  Mott 
and  Halliburton.  The  quantity  of  fluid  contained  in  the 
ventricles  and  subarachnoid  spaces  of  the  brain  and  the 
corresponding  spaces  of  the  cord  is  about  100-130  c.c. 
Judging  from  the  way  it  gushes  out  when  the  membranes 
are  punctured  by  a  needle  and  cannula  in  the  lower  lumbar 
region,  it  exists  under  considerable  pressure. 

The  sources  of  this  fluid  are  the  choroid  plexuses  of  the 
ventricles.     These  villous  structures  are  familiar  to  all  anato- 


GEBEBR0-8FINAL    FLUID  637 

mists.  They  consist  of  tufts  of  blood-vessels  surroimdecl  by- 
loose  connective  tissue  covered  by  a  single  layer  of  cubical 
or  spheroidal  epithelium  resting  on  a  basement  membrane. 
These  tufts  are  well  supplied  with  fine  nerves. 

Although  nothing  is  known  with  certainty  on  the 
point,  it  is  supposed  that  the  cerebro-spinal  fluid  exercises 
mechanical  functions ;  as  the  whole  of  the  central  nervous 
system  is  contained  in  a  closed  membranous  sac,  all  the 
space  which  is  not  occupied  by  tissue,  or  blood,  is  filled  with, 
it.  The  intraventricular  spaces  communicate  with  the  sub- 
arachnoid spaces  at  the  lateral  angles  of  the  fourth  ventricle ; 
the  actual  lopenings  are  known  as  the  lateral  recesses.  In 
spite  of  much  careful  dissection  I  have  failed  to  detect  the 
opening  at  the  lower  part  of  the  fourth  ventricle  known  as 
the  foramen  of  Magendie.  Mechanical  interference  with  the 
intraventricular  communications  will  lead  to  distension 
of  the  lateral  ventricles. 


CHAPTER  LXIl 

PSEUDO-CYSTS    (Concluded) 

NEURAL   CYSTS   (Concluded) 

Spina  bifida. — The  term  spina  bifida  is  applied  to  congenital 
defects  in  the  union  of  the  laminae  of  one  or  more  vertebrae, 


Central  canal  of 
the  cord. 


,^^,      -    Expanded  nerve 
.iS;  tissue. 


Fig.  336. — Lumbar  region  of  a  fcstus  with  spina  bifida,  variety  myelocele.     {After 
Shattoch.)     {Museum,  Middlesex  Hospital.) 

associated    with    malformation    of    the    sj)inal   cord   or    its 
membranes. 

The  spinal  cord  and  a  large  part  of  the  bram  are  formed 
by  the  dorsal  coalescence  of  the  medullary  folds.  The  fusion 
of  these  folds  commences  in  the  thoracic  and  extends  into 
the  cephalic  and  caudal  regions.  For  a  short  time  after 
coalescence  the  embryonic  cord  and  superficial  epiblast  re- 
main in  contact.  Gradually  they  become  separated  by  the 
intrusion  of  connective  tissue,  some  of  which  chondrifies  and 

638 


MYELOCELE 


639 


afterwards  ossifies  to  form  vertebrae  and  intervertebral  discs. 
In  the  early  stages  the  cord  has  a  longitudinal  extent  equal 
to  that  of  the  notochord,  and  this  equality  is  maintained  for 
some  time  after  the  closure  of  the  medullary  groove.  Subse- 
quently the  vertebral  column  grows  at  a  greater  rate  than  the 
nerve- tube  ;  the  result  is  that  at  birth  the  medullary  cone  at 
the  end  of  the  cord  is  opposite  the  upper  border  of  the  second 
lumbar  vertebra. 

The  varieties  of  spina  bifida  are  determined  according  to 
the  stage  of  development  at  which  the  defect  occurs,  as  de- 
termined by  the  anatomy  of  the  parts.     They  are — 

1,  Myelocele  ;  2,  syringo-myelocele ;  3,  meningo-myelocele ; 
4,  meningocele ;  5,  masked  spina  bifida  {spina  bifida  occulta) 


Fig.  337. — Diagram  to  represent  the  microscopic  characters  of  a  transverse  section 

of  a  myelocele. 

1.  The  7nedv2lary  folds  mcty  unite  imperfectly  and  give 
rise  to  a  myelocele  (Fig.  336). 

In  this  case  the  cord  is  normally  formed  in  the  cervical 
and  thoracic  regions,  but  in  the  lumbar  portion  the  central 
canal  suddenly  opens  on  to  a  shallow  depression,  the  sides  of 
which  are  slightly  intumescent  and  then  become  gradually 
continuous  with  the  skin.  The  tissue  surrounding  the  furrow 
represents  the  medullary  folds  and  consists  mainly  of  very 
vascular  nerve-tissue.  When  fresh  this  area  is  bright-red  and 
resembles  a  nsevus. 

When  this  red  tissue  is  carefully  dissected  from  the 
underlying  vertebrae  and  prepared  for  the  microscope,  it  will 
exhibit  on  each  side  of  the  furrow  nerve-cells  embedded  in 
neuroglia  intermixed  with  plexuses  of  arterioles,  venules,  and 


640 


PSEUnO-GYSTS 


capillaries  (Fig.  337).  It  is  hard  to  determine  the  existence 
of  epithelium  on  the  surface  of  myeloceles,  because  there  is 
usually  some  inflammation,  and  occasionally  sloughing. 

Myeloceles  are,  according  to  my  observations,  more  com- 
mon in  the  stillborn  than  in  children  who  survive  their  birth 
a  few  days. 

Children  with  myeloceles  rarely  live  more  than  a  few 
days.  This  variety  of  spina  bifida  is  often  associated  with 
defects  in  other  regions  of  the  body,  including  the  brain 
which  are  incompatible  with  life. 

2.  The  medullary  folds  unite  througJiout,  hut  fail  to 
separate  from,  the  surface  epiblast.  The  central  canal  hecomies 
subsequently  dilated :  syringo-myelocele. 

Syringo- myelocele  is  a  rare 
variety  of  spina  bifida,  and  cannot 
be  distinguished  from  simpler 
forms  during  life.  When  the  parts 
are  dissected  the  nerves  will  be 
found  passing  round  the  convexity 
of  the  cyst  (Fig.  338). 

Although  syringo-myelocele  is 
rare  in  a  typical  form,  it  may 
occur  in  combination  with  a  men- 
ingocele. Glutton  has  carefully 
described  an  example  (Fig.  339). 

3.  The  cord  is  normcdly  closed,  but,  before  it  separates 
from  the  surface  epiblast,  becomes  compressed,  by  a  collection 
of  fluid  within  the  meningeal  spaces  :  mening-o-myelocele. 

"  Probably  two-thirds  of  all  cases  of  spina  bifida  that 
survive  birth  are  meningo-myeloceles.  The  condition  is 
easily  recognized ;  there  is  a  deficiency  in  the  arches  of  the 
vertebrae,  usually  in  the  lumbar  region,  occupied  by  a  cyst  of 
variable  size.  Unless  inflamed,  or  flaccid  in  consequence  of 
leakage,  the  cyst  is  translucent  and  often  presents  a  pink 
tinge.  Its  most  posterior  part  is  somewhat  flattened,  and 
occasionally  a  shallow  median  groove  is  seen.  In  some 
specimens,  quite  in  the  centre  of  the  cyst  there  is  a  small 
umbilicus  marking  the  central  canal  of  the  cord.  At  the 
edge  of  the  cyst,  where  its  walls  become  continuous  with  the 
skin,  the  margin  is  slightly  raised,  and  immediately  beyond 


Fig.  338.— Syringo-myelocele  in 
transverse  section. 


SPINAL  MENINGOCELE 


641 


this  tlie  skin,  even  in  tlie  new-born,  may  present  a  circle  of 
long  hairs. 

Meningo-myeloceles  are  often  associated  with  hydrocepha- 
lus and,  in  a  large  proportion  of  cases,  with  double  talipes 
equino-varus  and  other  severe  deformities  of  the  lower  limbs. 

On  transverse  section  of  a  meningo-myelocele  the  cord 
is  found  flattened  on  the  posterior  wall  of  the  cyst  like  a 
strap,  Avhilst  the  nerves  reach  their  respective  foramina  by 
directly  traversing  the  cavity  of  the  cyst  (Fig.  340). 


Sac     of    tlie 
meningocele. 


Fig.  339. — Syi'ingo- myelocele  and  meningocele  in  longitudinal  section  ;   from  the 
cervical  region.     [After  Glutton.) 

That  the  strap-like  band  of  nerve-tissue  on  the  posterior 
wall  of  the  sac  is  the  flattened  spinal  cord  was  demonstrated 
by  Shattock.  .He  cut  sections  of  this  part  of  the  cyst  and 
detected  the  central  canal  (Fig.  341). 

4.  The  cord  is  normal,  hut  there  is  a  local  hernia  of  the 
membranes  :  meningocele. 

Protrusion  of  the  membranes  unaccompanied  by  the  cord 
is  by  no  means  common  in  spina  bifida.  Although  it  has 
been  met  with  in  the  cervical  region  of  the  spine,  it  most 
frequently  affects  the  lumbo-sacral  region,  or  may  be  con- 
fined to  the  sacral  portion  of  the  spine.  Some  writers  on 
this  malformation  believe  that  the  hernial  protrusion  may 
make  its  way  between  the  arches  of  two  vertebrse  instead  of 
2  p 


642 


PSEUDO-CYSTS 


between  the  laminte  of  a  single  vertebra.  It  is  a  fact  that 
the  sac  of  a  meningocele  sometimes  emerges  through  a  very 
narrow  orifice,  and  in  a  few  instances 
this  causes  the  cyst  to  become  more 
or  less  pedunculated,  and  may  lead  to 
occlusion  of  the  aperture  by  Avhich 
the  dural  space  and  the  cyst  com- 
municate and  thus  isolate  the  cyst. 

Virchow  investigated  a  remarkable 
specimen  ilhistrating  this  process. 
The  patient  was  a  negro  child  born 
with  a  large  tumour  pendulous  from 
its  buttock  (Fig.  342).  The  tumour 
was  removed  in  Central  Africa  and 
sent  to  Virchow,  under  the  impression 
that  it  was  a  fatty  tumour.  Dis- 
section revealed  a  central  space  in 
the  tumour  lined  with  dura  mater, 
which  was  covered  with  fat  intermixed  with  muscle-tissue. 
The  structure  and  arrangement  of  the  parts  were  such  as  to 
lead  Virchow  to  the  opinion  that  the  tumour  was  the  sac  of  a 
meningocele  (Fig.  343). 

A  tumour  in  many  respects  similar  to  this,  save  that  it 


I 


Fig.  340. — Diagram  showing 
a  meningo-myelocele  in  trans- 
verse section.  The  cord  is 
flattened  on  the  posterior  wall 
of  the  cyst,  and  the  nerves 
traverse  its  cavity. 


Fig.  341. — IVIicroscoirical  appearances  of  the  nerve-tissue  from  the  wall  of  a  meningo- 
myelocele showing  the  central  canal.     {Jifter  Shaitock.) 

occurred  in  the  cervical  region  of  the  spine,  was  removed 
by  Solly  in  1856  from  a  woman  27  years  of  age.  The 
description  of  the  case  is  accompanied  by  an  exceedingly 
interesting  clinical  history,     Pj^otrusions  of  dura  mater  uii- 


SPINAL  MENINGOCELE 


US 


accompanied  by  cord  or  nerves  (meningoceles)  are  more 
common  in  the  sacral  region  than  elsewhere.  In  some 
instances  the  membranes  emerge  through  the  deficiency 
(hiatus  sacralis)  normally  present  below  the  third  sacral 
vertebra. 

This  will  perhaps  be  the  most  convenient  place  in  which 
to  refer  to  an  abnormal  disposition  of  the  cord  which  I  have 


Fig.  342. — African  child  with  a  pedunculated  tumoui-  (an  occluded  spiua  bifida  sac) 
attached  to  its  buttock.     (After  Virchoiv.) 


met  with  in  association  with  spina  bifida.  It  is  well  known 
that  in  the  early  embryo  the  cord  extends  the  whole  length  of 
the  vertebral  column,  but  at  birth  the  apex  of  the  medullary 
cone  is  on  a  level  with  the  upper  border  of  the  second  lumbar 
vertebra.  I  have  placed  in  the  museum  of  the  Middlesex 
Hospital  a  spine  with  a  large  meningocele  m  the  sacral 
region ;  the  cord  runs  the  whole  length  of  the  neural  canal 
and  terminates  near  the  tip  of  the  sacrum  (Fig.  344). 


6U 


FSEUDO-GYSTS 


5.  The  cord  and  its  memhranes  are  normally  formed,  but 
the  arches  of  one  or  more  vertebrce  are  defective.  There  is, 
hoivever,  no  protrusion  of  the  membranes  or  cord :  masked 
spina  bifida  (spina  bifida  occulta). 

This  defect,  as  it  is  unaccompanied  by  a  cyst,  is  very  apt 
to  be  overlooked.  An  interesting  feature  usually  associated 
with  the  condition  is  an  abnormal  growth  of  hair  in  the  loins. 
Hair-fields  of  this  description  may  be  localized  to  the  loin,  as 
in  the  original  case  described  by  Virchow,  and  the  hair  may 
form  a  long  tuft  (Fig.  345).    In  exceptional  cases  an  abnormal 


Fig.  343. — Tumour  from  the  African  child  (see  Fig.  342),  shown  in  section. 


growth  of  hair  may  extend  from  the  loins  over  the  buttocks 
and  for  a  considerable  distance  down  the  thighs. 

The  two  varieties  observed  in  the  distribution  of  hair  in 
these  cases  are  well  illustrated  by  the  arrangement  adopted 
by  artists  and  sculptors  in  their  representations  of  fauns  and 
the  goat-footed  satyrs  (Fig,  346). 

Many  cases  of  spina  bifida  in  addition  to  the  "  masked  " 
species  are  accompanied  by  an  excessive  development  of  hair 
in  the  loin.  Attention  has  also  been  drawn  to  the  fact  that  a 
circlet  of  hairs  is  often  observed  on  the  skin  immediately 
l)ordering  the  sac  of  a  meningo-myelocele,  even  in  new-born 


SFINA   BIFIDA 


645 


babes.  Hair-fields  associated  with  occult  spina  bifida  are 
sometimes  mistaken  for  hairy  moles,  and  surgeons  have  in 
some  instances  Avith  misplaced  industry  removed  them  under 
that  im]3ression. 

This  excessive  develoj^ment  of 
hair  (hypertrichosis)  associated 
with  defective  closure  of  the  neural 
arches  is  interesting  when  studied 
in  connexion  with  the  luxuriant 
growth  of  feathers  on  the  heads 
of  Polish  fowls,  for  in  many  of 
these  birds  there  is  defective  ossifi- 
cation of  the  bones  of  the  cranial 
vault.  In  contrast,  it  should  be 
mentioned  that  the  bone  beneath 
the  exquisite  crest  of  the  crowned 
crane  is  abnormally  thick.  An 
important  condition  often  associ- 
ated with  spina  bifida  occulta  is 
perforating  ulcer  of  the  foot.  In- 
deed, this  association  is  now  so 
well  recognized  that  in  every  case 
of  perforating  ulcer  of  the  foot, 
occurring  in  young  patients,  it  is 
the  duty  of  the  surgeon,  as  a 
matter  of  routine,  to  examine  the 
loins. 

In  addition  to  non-union  of  the 
arches  in  the  vicinity  of  spina 
bifida,  the  vertebrae  are  liable  to 
be  defective  in  other  ways,  and  of 
these  defects  the  most  striking  is 
the  absence  of  half  a  vertebra — 
that  is,  half  the  centrum,  with  its 
pedicle,  lamina,  transverse,  articular 
and   spinous    processes,  is   wholly 

wanting.  The  persistent  half  of  such  a  vertebra  has  the 
characters  shown  in  Fig.  347,  and  is  often  ankylosed  to  the 
vertebra  above  and  below.  Sometimes  the  half-vertebra  is  in 
excess  of  the  ordinary  number.     Exceptionally,  a  considerable 


Fig.  344. — Spinal  column  in 
section  with  a  sacral  meningo- 
cele. The  spinal  cord  is  re- 
tained in  the  sacral  section  of 
the  neural  canal,  its  embryonic 
position.  From  a  child  aged 
3  months. 


646 


PSEUDO- CYSTS 


extent  of  the  column  will  be  replaced  by  an  alternating 
series  of  lialf-vertebree  ;  this  is  especially  seen  when  the  cer- 
vical portion  of  the  column  is  the  seat  of  spina  bifida. 

Half-vertebra3  occur  occasionally  independently  of  spina 
bifida  ;  they  have  also  been  detected  in  the  spines  of  snakes, 
calves,  fish  (sole),  and  rabbits.  The  aniount  of  disturbance 
sometimes  caused  in  a  vertebral  column  b}^  spina  bifida  is 
very  remarkable.     Occasionally,  horizontal  ]3rocesses  of  bone 

project  from  the  vertebral  centra 
into  the  neui'al  canal,  and  some- 
times transfix  the  cord.  Several 
examples  have  been  carefidly 
described  in  which  the  cord  has 
bifurcated  and  coalesced  again 
in  order  to  enclose  a  beam  of 
bone  crossino'  the  canal  in  a 
sagittal  direction. 

Complications  of  spina 
bifida.  —  Unfortunately  all 
species  of  spina  bifida  are  apt 
to  be  associated  with  other  se- 
rious conditions,  such  as  talipes 
ecjuino-varus,  single  and  double 
and  other  gross  deformities  of 
the  legs,  hydrocephalus,  men- 
ino'ocele,  and  malformations  of 
the  alimentary  canal,  such  as 
imperforate  aims  and,  on  rare 
occasions,  imperforate  pharynx. 
Very  exceptionally  these  two 
imperforate  conditions  of  the  ali- 
mentary canal  have  co-existed. 
The  most  serious  complication  of  spina  bifida  is  hydro- 
cephalus (p.  629).  The  ventricular  cavities  of  the  brain  may  be 
abnormally  dilated  at  birth  :  in  many  cases  the  hydrocephalus 
slowly  develops  during  the  first  few  weeks  of  infant  life,  and 
the  head  gradually  assumes  enormous  dimensions.  In  a 
small  proportion  of  cases  the  sac  of  the  spina  bifida  spon- 
taneously shrinks;  coincidently  with  this  the  fontanelles 
gradually  widen  and   hydrocephalus    develops.      I   have   in 


Fig.    345. —  Hair-field    overlying    a 

spina  bifida  occulta  ;  there  is  also  a 

long    tuft    in    the    cervical    region. 

(FiscJier.) 


SPINA    BIFIDA  647 

several  children  seen  liydroceplialus  supervene  when  the  sac 
in  the  loin  has  been  made  to  shrink  by  artificial  means. 

We  have  now  to  consider  the  various  modes  by  which 
spina  bifida  destroys  life.  Of  all  the  varieties  of  this  malfor- 
mation, myelocele  is  the  most  fatal.  A  very  large  proportion 
of  fcetuses  in  which  this  condition  is  present  are  stillborn; 
the  few  that  survive  their  birth  rarely  live  longer  than 
three  da3^s,  the  continual  leakage  of  cerebro-spinal  fluid 
being  sufficient  to  explain  the  invariable  brevity  of  their 
lives. 


Fig.  346. — ^gipan  sporting  with  a  faun.     (Bacchus  and  Sileuus.) 

When  a  distinct  sac  is  present,  life  may  be  prolonged 
many  weeks,  even  when  the  sac-wall  is  thin ;  Avhen  it  is  thick 
life  may  be  prolonged  several  years ;  and  when  it  is  com- 
pletely skin-covered,  some  of  these  children  survive  and  grow 
up  to  be  healthy  men  and  women.  The  prospects  of  each 
particular  case  are  largely  influenced  by  the  thickness  of 
the  sac-wall  and  the  absence  of  complications,  especially 
hydrocephalus. 

In  many  cases,  especially  when  the  walls  of  the  cyst  are 
thin,  the  tissue  is  apt  to  slough — an  event  that  allows  the 


648 


PSEUDO-CYSTS 


sudden  escape  of  the  cerebro-spinal  fluid  and  may  terminate 
the  hfe  of  the  child  in  a  few  hours.  Children  often  survive 
this  accident,  to  succumb  seven  or  ten  days  later  to  septic 
meningitis.  Exceptional!}'',  I  have  observed  children  recover 
from  rupture  of  the  sac  and,  escaping  meningitis,  slowly  die 
from  hydrocephalus.  Occasionally  the  sac  in  the  loin  and 
the  hydrocephalus  will  increase  simultaneously.  In  such  a 
case  pressure  on  the  anterior  fontanelle  will  increase  the 
tension  in  the  spina  bifida  sac,  and  vice  versa. 


Fig.  347.— Half -vertebra.     {After  Shattock.) 

The  duration  of  a  child's  life  with  spina  bifida,  excepting 
the  "  masked  "  species,  is  very  uncertain  ;  it  is  often  prolonged 
when  the  nurse  and  mother  are  careful  and  vigilantly  pre- 
serve the  sac  from  injury. 

That  spina  bifida  is  a  serious  affection  may  be  gathered 
from  the  figures  in  the  Registrar-General's  Reports  ;  about 
800  individuals  in  England  die  from  it  every  year.  This  in- 
formation is  not  precise,  as  the  actual  number  of  cases  is 
much  greater,  the  birth  of  the  stillborn  not  being  regis- 
tered. iSiO  facts  are  accessible  that  will  enable  an  estimate 
to  be  formed  of  the  real  frequency  of  the  malformation. 

Treatment. — This  has  undergone  a  great  change  in  re- 


SPINA  BIFIDA 


649 


cent  years.  Instead  of  the  slow  and  uncertain  method  of 
injection  with  iodo-glycerine  solution,  it  has  been  shown  that 
spina-sacs  may  be  safely  excised. 

The  evolution  of  the  central  nervous  system. — The 
extraordinary  frequency  with  which  the  membranous  and 
bony  coverings  of  the  central  nervous  system  are  malformed 


Fig.  348. — Meningeal  lipoma  simulating  a  spina  bifida  in  a  child 
8  months  old.     {After  Temoin.) 

induced  me  some  years  ago  to  investigate  the  abnormalities 
collectively  classed  under  the  term  spina  bifida,  with  the 
hope  of  obtaining  some  light  as  to  the  mode  of  evolution  of 
the  brain  and  spinal  cord,  for,  as  I  pointed  out  in  1886,  the 
pathological  behaviour  of  the  central  canal  of  the  cord  indi- 
cated that  it  was  an  obsolete  passage.  In  1887  I  came  to  the 
conclusion  from  embryological  and  pathological  data  that 
the  brain  and  cord  were  in  all  probability  evolved  from  a 


650  PSEUDO-CYSTS 

segment  of  the  lyrimitive  intestine.  This  view  has  been  con- 
firmed since  by  the  inde^Dendent  researches  of  Gaskell. 

Andriezen  demonstrated  the  existence  in  amphioxus 
and  ammocoetes  of  an  epithehum-Uned  duct  extending  from 
the  buccal  cavity  into  the  ventricle  (thalamocele),  and  suc- 
ceeded in  transmitting  carmine  particles  suspended  in  water 
into  the  central  canal  of  the  cord.  His  view  is  that  the 
central  canal  of  the  cord  is  a  remnant  of  the  water- vascular 
system. 

Tails. — This  account  of  spina  bifida  would  be  imperfect 
without  a  brief  notice  of  tails,  real  and  supposed,  in  the  human 
subject.  We  may  with  Virchow  arrange  tails  in  two  classes, 
true  and  false.  True  tails  may  be  complete  or  incomplete  : 
the  most  perfect  or  complete  tails  contain  bony  segments 
(vertebrse),  as  in  the  case  of  cats  and  dogs ;  the  less  perfect 
or  incomplete  tails  are  like  those  of  pigs^  soft  and  flexible. 
No  one  has  yet  reported  an  example  of  a  tail  in  the  human 
subject  containing  bony  elements.  Several  cases  have  been 
investigated  in  which  an  appendage  5  cm.  long,  and  soft  like 
a  pig's  tail,  has  been  found  directly  continuous  with  the 
coccygeal  vertebrte. 

Most  of  the  cases  reported  as  tails  were  nothing  more 
than  examples  of  congenital  sacro-coccygeal  tumours,  or  a 
tuft  of  hair  covering  a  masked  spina  bifida.  Tumours  sup- 
posed to  be  tails  were  in  some  cases  dermoids ;  in  others 
fatty  tumours  (Fig.  348),  or  the  sac  of  a  spina  bifida,  and  in 
many  cases  teratomas. 

Andriezen,  W.  L.,  "The  Morphology,  Origin  and  Evolution  of  Fanction  of  the 
Pituitary  Body,  and  its  relation  to  the  Central  Nervous  System." — Brit. 
Med.  Journ.,  189i,  i.  54. 

Bland-Sutton,  J.,  "On  the  relation  of  the  Central  Nervous  System  to  the 
Alimentary  Canal:  A  Study  in  Evolution." — Brain,  1888,  x.  429. 

Glutton,  H.  H.,  "  Large  Cervical  Spina  Bifida  undergoing  spontaneous  cure." — 
Trans.  Clin.  Soc,  188G,  xix.  99. 

Evans,  Z.  H.,  Intermit.  Journ.  of  Surrj.,  1895. 

Gaskell,  W.  H.,  "  On  the  relation  between  the  structure,  fanction,  distribution, 
and  origin  of  the  Cranial  Nerves  ;  together  with  a  theory  of  the  origin  of 
the  Nervous  System  of  the  Vertebrata." — Journ.  of  Phys.,  1889,  x.  153. 

Humphry,  Sir  George,  "  Six  specimens  of  Spina  Bifida,  with  bony  projections 
from  the  bodies  of  the  vertebrae  into  the  vertebral  canal." — Journ.  of  Anat. 
and  Phys.,  1886,  xx.  585. 


BEFEBENGES  651 

NicoU,  J.  H.,  "  The  Operative  Treatment  of  Spina  Bifida  and  Hydrocephalus." — 
Glasgow  llos]}.  Re])ts.,  1899,  ii.  297. 

Shattock,  S.  G.,  "  Eeport  of  a  Committee  of  the  Clinical  Society  of  London 
nominated  to  investigate  Spina  Bifida  and  its  treatment  by  the  injection 
of  Dr.  Morton's  lodo-glycerlne  Solution." — Trans.  Clin.  Soc,  1885,  xviii. 
355. 

Solly,  Samuel,  '•  Case  in  which  a  large  Cyst  was  successfully  removed  from 
the  upper  part  of  the  neck  of  a  young  woman  aged  27,  who  was  con- 
sidered at  birth  to  have  been  the  subject  of  Spina  Bifida." — Mecl.-Chir. 
Trans.,  1857,  xl.  19. 

Virchow,  'Rudolf.— Zeitsohr./.  Ethnologie,  1875,  vii.,  280,  t.  xvii.  Fig.  2. 

Virchow,  Rudolf,  "  Schwanzbildung  beim  Menschen." — Serl,  Min.  Woch.,  1884, 
xxi.  745. 

Virchow,  Rudolf,  "  Ueber  einen  Fall  von  Hygroma  cysticum  giutjeale  con- 
genitum." — Virchow's  Arclt.f.jrath.  Anat.,  1885,  c.  571. 


CHAPTER  LXIII 


ECHINOCOCCUS   DISEASE   (HYDATID    CYSTS) 

The  term  hydatid  formerly  covered  a  large  number  of 
pathological  productions,  but  is  now  restricted  in  human  path- 
ology to  the  cystic  stage  of  the  tapeworm  Tcenia  echinococcus. 
This  cestode,  which  in  its  mature  form  inhabits  the  intestines 
of  dogs,  is  about  4  mm.  in  length  and  consists  of  four  seg- 
ments, of  which  the  fourth  is  larger  than  the  rest  of  the  body 
and  is  the  only  segment  that  becomes  mature 
(Fig.  349). 

In  referring  to  T.  echinococcus  in  the  mucous 
membrane  of  the  dog's  intestine,  Leuckart  writes 
that  it  "  occurs  in  considerable  numbers,  some- 
times in  many  thousands,  between  the  villi,  so 
that  only  the  milk-white  proglottides  project." 
It  has  been  calculated  that  a  ripe  proglottis  of 
this  cestode  contains  about  5,000  ova.  This  is 
a  good  example  of  the  prodigality  of  nature  in 
all  that  concerns  eggs,  both  animal  and  vegetable. 
The  eggs  of  this  worm  are  passively  conveyed 
with  either  food  or  water  into  the  alimentary 
canal  of  man,  where  they  are  hatched ;  the 
embryos  migrate  from  the  intestine  into  some 
vascular  organ  or  tissue,  or,  by  gaining  entrance 
into  a  blood-vessel,  are  passively  conveyed  into 
some  distant  part  of  the  body  and  become 
transformed  into  cysts.  The  degree  of  infection 
depends  upon  the  number  of  ova  swallowed,  and  the  ex- 
traordinary multitude  of  cysts  and  colonies  found  in  some 
patients  would  suggest  that  an  entire  proglottis  had  been 
ingested. 

The  cyst-wall  has  a  peculiar  structure  ;  it  consists  of  an 
external  highly  elastic,  lamellar  cuticle,  and  an  internal  lining 

652 


X,(2 

Fig.  349.— 

Tsenia 

echinococcus. 

{Leuckart.) 


BROOD-CAPSULES 


653 


consisting  of  sfranular  matter,  cells,  muscle-tissue,  and  a  water- 
vascular  system  (Fig.  350). 

The  inner  lining  is  often  referred  to  as  the  parenchy- 
matous layer.  In  addition  to  the  proper  tissues  of  the  cyst, 
there  is  often  a  more  or  less  complete  fibrous  capsule, 
especially  when  the  cyst  projects  into  the  peritoneal  cavity. 
The  mode  by  which  these  adventitious  capsules  are  formed 
is  discussed  on  p.  628.  The  true  cyst  is  maintained  in 
apposition  with  the  fibrous  capsule  by  the  pressure  of  the 
contained  fluid ;  when  this  is  removed  by  the  abstraction  or 
escape  of  the  fluid,  the  mother-cyst  at  once  collapses. 

The  fluid  is  clear,  limpid,  colourless  or  slightly  opalescent ; 
specific  gravity,  1004  to  1015;  it  contains  chloride  of  sodium, 


Fig.    350.— Small   echinococcus   cyst,  showing  the  peculiar  lamination  of  its  wall. 

{Lenckaft.) 

succinic  acid,  and  occasionally,  in  cysts  situated  in  the  liver, 
leucin,  tyrosin,  and  sugar.  Hooklets  and  scolices  are  also 
found. 

When  the  hydatid  attains  the  size  of  a  walnut,  small 
vesicles  or  brood-capsules  develop  from  the  parenchymatous 
layer.  These  brood-capsules  develop  numbers  of  heads  or 
scolices.  The  scolex  when  fully  developed  is  about  0  3  mm. 
long,  is  furnished  Avith  four  sucking  discs  and  a  rostellum 
of  tiny  blunt  hooklets ;  it  has  a  water-vascular  system  and 
numerous  calcareous  particles.  The  fore  part  of  the  scolex 
can  be  withdrawn  into  the  hinder  part ;  indeed,  this  is  the 
position  in  which  they  are  usually  found  (Fig.  351). 

As  fresh  brood-capsules  and  scolices  are  formed,  the  cyst 
enlarges,  and,  when  seated  in  an  organ  or  cavity  of  the  body 
which  imposes  little  restraint  upon  its  growth,  it  may  attain 


654 


HYDATID   GTSTS 


enormous  proportions — e.g.  hydatid  cysts  of  the  liver  have 
been  known  to  acquire  a  capacity  of  sixteen  pints. 

In  many  hydatids  daughter-cysts  are  formed  from  brood- 
capsules  and  probably  from  scolices.  Cysts  containing  large 
numbers  of  these  translucent  thin-walled  vesicles  are  known 
as  echinococcus  colonies. 

Occasionally  cysts  even  of  large  size  do  not  contain 
vesicles  or  brood -capsules ;  such  are  said  to  be  sterile.  The 
walls  of  sterile  hydatids  exhibit  the  characteristic  lamination, 
and  this  enables  the  nature  of  the  cyst  to  be  recognized  in 
otherwise  doubtful  cases. 

Echinococcus  multilocularis  (Virchow). — This  is  an  ex- 
ceptional mode  in  which  echinococcus  disease  manifests  itself, 


Fig.  351. — Portion  of   the  cyst-wall   of  an  echinococcus  colony,  showing  scolices. 

{Leiickart.) 

or,  as  Ziegler  thinks,  a  distinct  species.  In  this  condition  the 
vesicles  are  of  small  size,  but  occur  in  great  number,  and  are 
not  contained  in  a  mother-cyst.  The  vesicles  in  such  cases 
rarely  exceed  a  pea  in  size,  but  the  majority  are  much  smaller ; 
very  many  are  no  larger  than  millet-  or  rape-seed.  This 
variety  occurs  most  frequently  in  the  shafts  of  long  bones; 
it  has  also  been  observed  in  the  spinal  canal. 

The  multilocular  hydatid  occurs  in  the  liver  as  a  firm 
tumour;  on  section  it  presents  trabeculse  of  dense  fibrous 
tissue  causing  it  to  assume  an  alveolar  appearance.  The 
alveoli  contain  a  gelatinous  substance  in  which  the  shrunken 
vesicles  are  embedded. 

Most  of  these  minute  vesicles  are  sterile,  but  here  and 
there  a  few  booklets  can  with  patience  be  demonstrated, 
Virchow  was   the  first  to  detect  the  hydatid  nature  of  such 


HYDATID  BASH  655 

tumours  in  the  liver ;  previously  they  had  been  described 
as  colloid  cancer.  In  very  rare  instances  contracted  and 
shrunken  vesicles  embedded  in  gelatinous  material  and  sur- 
rounded by  a  distinct  cyst  have  been  observed  in  the  liver. 
E.  multilocidaris  has  also  been  found  in  the  brain  and 
lung  (Ziegler). 

Hydatid  rash. — When  the  fluid  from  an  echinococcus  cyst 
escapes  into  the  peritoneal  cavity  it  is  apt  to  produce  an 
urticarial  eruption  known  as  the  hydatid  rash.  It  usually 
appears  shortly  after  the  cyst  has  been  ruptured  or  punctured  ; 
it  itches  intensely,  lasts  two  or  three  days,  and  is  usually 
accompanied  by  high  temperature  and  sometimes  by  abdo- 
minal pain.  It  is  referred  to  by  several  observers.  Krabbe 
writes  :  "  A  curious  phenomenon  is  habitually  observed  when 
hydatids  rupture  into  the  peritoneal  cavity :  it  provokes  a 
transient  urticaria." 

Finsen  refers  to  two  cases  worth  mentioning  in  rela- 
tion to  the  rash.  Paul  Helgason,  aged  12  years,  had  for  four 
years  a  large  tumour  in  the  right  hypochondrium  extending 
to  the  umbilicus.  The  lad  received  a  blow  upon  the  belly 
from  a  cow's  horn  that  caused  the  tumour  to  disappear. 
Almost  immediately  the  body  was  covered  with  a  rash  like 
an  urticaria,  but  it  soon  disappeared. 

In  another  instance,  a  pregnant  woman  had  a  hepatic 
hydatid  for  six  years.  Three  days  after  delivery,  Avhilst  lying 
quietly  in  bed,  she  was  suddenly  seized  with  acute  pain  in  the 
abdomen  ;  the  tumour  of  the  liver  disappeared,  and  in  a  short 
time  the  skin  presented  a  papular  rash. 

Hepatic  hydatids  may  be  accidentally  ruptured  in  a  variety 
of  ways — such  as  blows,  falls  on  the  belly,  by  the  wheels  of  a 
cart,  or  during  an  embrace  in  "  a  moment  of  exuberant  affec- 
tion "  (Treves). 

The  usual  mode  of  termination  of  an  echinococcus  cyst 
is  that  it  ceases  growing ;  it  then  dies,  shrivels  up,  and  calci- 
fies, assuming  a  friable  appearance  like  old  mortar. 

When  the  cyst  continues  to  grow  its  tendency  is  to 
rupture  ;  the  great  tension  exerted  by  the  accumulating 
fluid,  and  especially  the  formation  of  daughter-cysts,  induces 
necrosis  of  portions  of  the  cyst-wall.  When  contiguous  to 
hollow  viscera,  such  as  the  intestine,  stomach,  trachea,  and 


656  HYDATID   CYSTS 

the  like,  the  cyst  is  apt  to  come  into  contact  with  them,  and 
the  mutual  pressure  leads  to  absorption  of  the  intervening 
tissue,  and  allows  of  the  transmission  of  gas  or  air,  or  the 
osmosis  of  fluids  which  kill  the  parasite,  and  the  entrance  of 
pathogenic  micro-organisms  establishes  suppuration. 

In  many  cases  the  communications  between  the  colonies 
and  the  hollow  viscera  are  so  free  that  the  contents  are 
evacuated.  In  some  instances  this  is  a  fortunate  termina- 
tion ;  but  frequently  it  is  a  catastrophe  to  be  dreaded,  as  it 
leads  to  secondary  changes  that  have  ultimately  a  fatal  issue. 
In  rare  cases  the  vesicles  in  a  colony  become  converted 
into  colloid  material  of  about  the  consistence  of  gelatme. 

Geographically,  echinococcus  disease  has  a  very  wide 
distribution,  which  corresponds  with  that  of  the  dog.  It 
is,  however,  far  more  frequent  in  some  regions  of  the  world 
than  in  others,  especiall}^  where  sheep-raising  is  a  prime 
industry.  Iceland  is  notorious  for  the  frequency  with 
which  its  inhabitants  fall  victims  to  this  parasite ;  after 
allowing  great  latitude  for  errors  in  the  direction  of  excess 
in  calculating  its  frequency,  echinococcus  disease  must  be 
regarded  in  the  light  of  a  persistent  epidemic  so  far  as 
that  island  is  concerned. 

Next  to  Iceland,  Silesia  is  usually  regarded  as  the  most 
infested  district  in  Europe.  In  Australia  this  disease  is 
excessively  frequent,  and  whereas  most  of  the  monographs 
on  this  disease  in  its  clinical  aspects,  written  thirty  years 
ago,  were  founded  in  a  large  measure  on  observations  made 
in  Iceland,  we  now  look  to  the  writings  of  Australian 
physicians  and  surgeons  for  information  on  the  pathology, 
diagnosis,  and  treatment  of  echinococcus  colonies. 

In  Asia  the  disease  is  known :  it  occurs  in  India,  though  it 
is  far  from  common.  In  America  it  is  not  frequent ;  judging 
from  the  few  references  to  it  in  American  literature,  hydatids 
appear  to  be  far  rarer  in  North  America  than  in  the  British 
Isles. 

Zoologically,  echinococcus  disease  is  not  very  restricted, 
for  it  has  been  observed  in  monkeys,  lemurs,  cows,  sheep, 
goats,  deer,  camels,  antelopes,  giraffes,  ■  horses,  asses,  zebras, 
hogs,  squirrels,  and  kangaroos,  in  addition  to  man. 

Topographical  distribution  in  man. — Although  an  echino- 


CORPOREAL  DISTRIBUTION  657 

coccus  cyst  may  form  in  almost  any  organ  in  the  human 
body,  it  occurs  with  greater  frequency  in  some  organs  and 
tissues  than  in  others.  A  comparison  of  statistical  tables 
compiled  in  Iceland,  Germany,  Australia,  and  America  brings 
out  most  decisively  the  fact  that  hydatids  are  met  with  more 
frequently  in  the  liver  than  in  all  other  parts  of  the  body 
together ;  whilst  in  other  organs,  such  as  the  breast,  thyroid 
gland,  or  spinal  cord,  the  literature  of  a  century  would  furnish 
probably  under  a  score  of  trustworthy  cases. 

It  is  necessary  to  point  out,  in  regard  to  the  distribution 
of  echinococcus  colonies,  that  though  on  superficial  examina- 
tion they  may  appear  to  be  lodged  in  the  liver,  kidney,  uterus, 
or  rectum,  a  closer  and  more  critical  inquiry  shows  that  in 
nearly  all  instances  the  parasite  selects  the  loose  subserous 
tissue.  For  example,  echinococcus  cysts  in  the  liver  usually 
lie  in  the  tissue  beneath  the  peritoneum  covering  this  organ. 
This  is  certainly  true  of  the  uterus,  and  a  few  cases  reported 
as  growing  from  the  Fallopian  tube  or  ovary  are  really  cases 
of  infection  of  the  loose  connective  tissue  of  the  mesometrium. 
In  the  case  of  the  kidney  the  parasite  flourishes  in  the  con- 
nective tissue  of  the  renal  sinus. 

This  peculiar  preference  of  the  embryo  of  T.  echinococcus 
for  subserous  areolar  tissue  will  be  further  considered  in  de- 
scribing the  relationship  of  the  cysts  and  colonies  in  various 
organs.  Echinococcus  cysts  may  occur  singly  or  be  dis- 
tributed over  the  body  in  great  numbers.  The  effects  to 
which  they  give  rise  vary  with  the  situation  and  dimensions 
of  the  cyst.  For  instance,  a  cyst  of  such  a  size  as  to  cause  no 
inconvenience  when  seated  in  the  liver  would,  if  growing  in  the 
brain  or  in  the  walls  of  the  heart,  induce  death  from  mechani- 
cal causes.  Again,  a  colony  in  the  Hver  will  often  attain  a 
very  large  size  before  causing  inconvenience  to  the  patient, 
whereas  one  only  half  the  size  situated  in  the  pelvis  will 
produce  much  distress  by  interfering  with  the  function  of  the 
rectum  or  bladder.  On  the  other  hand,  a  small  cyst  in  the 
liver,  no  larger  than  an  orange,  when  accidentally  ruptured  so 
that  its  contents  escape  into  the  peritoneal  cavity,  may  rapidly 
destroy  hfe,  but  a  cyst  the  size  of  a  melon,  or  larger,  bursting 
into  the  rectum,  will  not  lead  to  much  trouble  ;  though  even 
a  small  cyst  so  seated  as  to  rupture  into  the  trachea  will, 
2  Q 


658 


HYDATID  GYSTS 


when  the  event  comes  to  pass,  almost 
by  suffocation.     Indeed,  the  ways  m 
colonies  kill  are  so  many  and  so  var 
dealt  Avith  under  each  organ. 

The  bursting  of  a  colony  into  the 
general  infection  of  the  peritoneum  ; 
grafting  themselves  on  this  membrane 
like  miliary  tuberculosis. 


inevitably  cause  death 
Avhich  these  cysts  and 
ious  that   they  will  be 

abdomen  may  lead  to 
the  brood-capsules  en- 
produce  an  appearance 


Fig.  3-52. — Portion  of  liver  in  which  the  interlobular  tissue  throughout  the  organ 
was  infested  with  echinococcus  cysts.     {Mtiseuin,  Jtoyal  College  of  Surgeons.) 

Liver. — Echinococcus  cysts  and  colonies,  as  we  have  seen, 
are  most  frequent  in  the  liver.  This  is  not  due  to  any 
selective  power  on  the  part  of  the  parasite,  but  to  the  fact 
that  it  finds  its  way  into  the  gastric  tributaries  of  the  portal 
vein,  and  is  passively  conveyed  into  the  gland.  As  a  rule,  a 
single  cyst  is  found  in  the  liver,  though  it  is  not  uncommon 
to  find  three  or  four ;  but  there  is  no  limit  to  their  number, 
and  the  museum  of  St.  Thomas's  Hospital  contains  a  liver 
weighing  nearly  twenty-five  pounds,  obtained   from  a  sailor 


HEPATIC  HYDATIDS  659 

in  1864,  which  is  occupied  by  hundreds  of  cysts.  The  case 
was  carefully  described  by  Peacock.  There  were  cysts  in  the 
lungs,  spleen,  kidney,  omentum,  and  right  ventricle  of  the 
heart.  A  portion  of  the  liver  is  in  the  museum  of  the  Royal 
College  of  Surgeons,  and  is  the  source  of  Fig.  352. 

A  critical  examination  of  the  distribution  of  the  cysts  and 
colonies  in  the  liver  demonstrates  that  their  primary  seat  is 
in  nearly  all  instances  the  connective  tissue  immediately  be- 
neath its  peritoneal  investment  or  in  the  portal  fissures.  In 
the  very  exceptional  cases  where  the  cysts  are  uniformly  dis- 
tributed through  the  organ,  as  in  Peacock's  sailor,  the  six- 
hooked  embryo  has  selected  the  interlobular  connective 
tissue.  Leuckart's  feeding  experiments  throw  a  good  light  on 
this  specimen.  His  greatest  success  occurred  with  the  pig, 
which  he  says  "  may  be  very  readily  infected  by  the  eggs  of 
Tcenia  echinococcus,"  and  he  points  out  that  "  it  is  remark- 
able that  the  cysts  were  all  thickly  distributed  under  the 
serous  covering  of  the  liver,  and  that  upon  both  the  concave 
and  convex  surfaces."  Leuckart  also  clearly  notices  the 
relation  of  this  parasite  to  the  connective  tissue  of  the  liver, 
for  he  distinctly  states  in  more  than  one  place  in  his  book 
that  these  early  cysts  were  "  everywhere  in  direct  continuity 
with  the  connective- tissue  trabecular  network  of  the  liver.'' 
And  he  writes  :  "  In  all  cases,  moreover,  it  was  the  interlobu- 
lar tissue  that  contained  the  parasites."  This  supports  the 
teaching  of  Naunyn,  that  the  embryos  are  distributed  by 
the  vascular  system. 

In  the  liver  of  the  sailor  we  have  an  example  of  infec- 
tion exceptionally  severe,  in  which  the  parasites  occupied 
the  interlobular  connective  tissue  of  the  organ  as  well  as  the 
subserous  tissue. 

The  relative  frequency  of  these  cysts  in  the  liver,  the 
large  size  they  attain  in  this  organ,  and  the  risk  they  occasion 
to  life  have  caused  them  to  be  very  attentively  studied. 

When  the  cyst  ruptures  spontaneously  it  may  take  various 
directions.  Thus,  it  may  burst  into  the  pleura  and  give  rise 
to  fatal  pleurisy.  Should  the  lung  be  adherent  to  the  dia- 
phragm, the  cyst  may  open  into  it  and  the  contents  be 
discharged  through  the  bronchial  tubes  and  trachea.  Under 
these  conditions  gangrene  of  the  lung  may  follow  the  rupture. 


660  HYDATID   GYSTS 

In  a  few  instances  the  cyst  has  burst  into  the  pericardium. 
Such  an  accident  is  rapidly  fatal,  as  the  inundation  of  the  peri- 
cardial cavity  with  fluid  and  vesicles  embarrasses  the  heart. 
In  some  cases  death  has  followed  from  pericarditis. 

Rupture  of  a  large  cyst  into  the  peritoneal  cavity  leads  to 
serious  consequences,  but  even  when  the  cyst  is  small  it  may 
lead  to  general  infection  of  the  peritoneum.  In  a  case  under 
my  care  there  was  reason  to  believe  that  a  hepatic  colony  had 
ruptured  into  the  lesser  bag  of  the  peritoneum,  for  the  whole 
of  the  small  omentum  was  thickly  beset  with  little  vesicles. 
Graham  records  a  similar  observation.  A  cyst  has  been 
known  to  rupture  into  the  stomach,  the  vesicles  being  after- 
wards vomited ;  and  some  have  burst  into  the  intestine,  the 
contents  of  the  cysts  being  discharged  by  the  anus. 

Among  the  rarer  directions,  hydatids  have  been  known 
to  rupture  into  the  biliary  passages,  the  obstruction  caused 
by  the  vesicles  has  induced  jaundice,  and  their  subsequent 
passage  along  the  common  duct  has  produced  biliary  colic. 
This  is  a  serious  complication  and  often  terminates  fatally. 
In  several  cases  which  have  been  carefully  investigated  the 
colony  opened  into  the  hepatic  duct.  The  museum  of  the 
Middlesex  Hospital  contains  a  specimen  illustrating  this,  and 
the  common  bile-duct  is  sufficiently  dilated  to  admit  an  index 
finger.     The  patient  was  under  the  care  of  Murchison. 

Another  excessively  rare  direction  is  for  the  cyst  to  rup- 
ture into  the  inferior  vena  cava,  the  contents  reaching  the 
right  side  of  the  heart. 

Cases  have  been  reported  in  which  the  pressure  of  a  cyst 
has  induced  atrophy  of  the  intercostals,  and  its  contents  have 
been  discharged  externally.  Cysts  have  also  been  known  to 
burst  externally  near  the  umbilicus.  Suppurating  cysts  may 
terminate  in  any  of  the  directions  mentioned  above. 

Hepatic  hydatids  may  cause  death  by  their  size  embar- 
rassing respiration ;  or  by  pressure  on  important  organs,  such 
as  the  vena  cava,  producing  anasarca;  or  by  hindering  the 
circulation  through  the  vena  portse  and  causing  ascites ; 
whilst  suppuration  will  lead  to  exhaustion  or  induce  death 
by  septicaemia  or  pyaemia. 

Heart. — Echinococcus  cysts  and  vesicles  are  met  with  in 
the  heart  under  two  conditions :    (1)  the  cyst  arises  in  the 


GAUD  I  AG  HYDATIDS  661 

loose  areolar  tissue  of  the  organ,  and  is  then  termed  "pri- 
mary " ;  or  (2)  the  vesicles  are  conveyed  into  the  cavities 
of  the  right  side  of  the  heart  as  emboli  in  consequence 
of  the  bursting  of  a  colony  into  some  large  efl'erent  vessel  like 
the  vena  cava. 

In  most  descriptions  of  "  hydatids  of  the  heart "  attention 
is  in  the  main  directed  to  the  relation  of  the  cysts  and  colo- 
nies to  the  chambers  of  this  organ,  but  a  critical  examination 
of  the  reports  and  specimens  serves  to  show  that  the  parasite 
exhibits  the  same  fondness  for  abiding  in  loose  areolar  tissue 
in  this  organ  as  in  others. 

The  heart  contains  in  the  auriculo-ventrieular  groove  a 
large  amount  of  loose  adipose  tissue  which  is  strictly  sub- 
serous. This  loose  tissue,  which  serves  as  a  bed  for  the 
coronary  vessels,  penetrates  deeply  between  the  adjacent 
walls  of  the  auricles,  and  indicates  on  the  ventricular  sur- 
face of  the  heart  the  line  of  the  interventricular  septum. 

A  critical  examination  of  some  of  the  available  specimens 
makes  it  clear  that  in  the  majority  of  instances  the  parasite 
lodges  in  the  loose  tissue  of  the  auriculo-ventrieular  septum. 

A  man  aged  19  years  died  in  Guy's  Hospital  with  extreme 
suffering  and  the  ordinary  symptoms  of  mitral  imperfection. 
On  examining  the  heart,  Moxon  found  a  projection  the 
size  of  an  apple  on  the  back  of  the  auricles,  "  off  their  septum 
near  where  it  joins  the  septum  of  the  ventricles  ;  from  its 
extent  it  implicated  all  those  parts  mentioned."  It  had 
completely  blocked  the  coronary  sinus.  The  cyst,  which  con- 
tained daughter-vesicles,  was  unbroken  (Fig.  353). 

A  study  of  this  specimen  shows  that  the  colony  arose 
in  the  loose  tissue  of  the  auriculo-ventrieular  groove  and 
came  into  close  relation  with  the  four  cardiac  cavities.  It  is 
a  noteworthy  fact  that  the  cyst  is  in  very  intimate  rela- 
tion with  the  interventricular  septum.  I  have  come  across 
several  records  in  which  the  cyst  is  described  as  occupying 
this  septum,  and,  on  examining  the  specimen  described  by 
Peacock,  which  is  preserved  in  the  museum  of  the  Royal 
College  of  Surgeons,  the  cyst  will  be  seen  to  occupy  its  upper 
(auricular)  end. 

The  effects  of  echinococcus  colonies  on  the  heart  and 
circulation  are  important.     A  cyst  may  exist  for  a  long  time 


662 


HYDATID   GYSTS 


and  give  no  indication  of  its  presence,  and  then  death  occurs 
suddenl}'  and  the  cause  is  manifest  at  the  post-mortem 
examination  (Peacock's  case).  In  others  the  cyst,  or  colony, 
embarrasses  the  action  of  the  heart  and  produces  serious 
symptoms  of  valvular  lesion  (Evans,  Moxon).  More  often 
the  cyst  bursts  into  one  of  the  cavities  of  the  heart,  the 
vesicles  and  membrane  being  deported  as  emboli.  When  the 
cavities  on  the  left  side  of  the  heart  are  invaded  the  vesicles 


Fig.  353. — Left  ventricle  of  heart  opened  vertically  to  expose  an  echinococcus 
colony  growing  in  the  loose  tissue  of  the  auriculo-ventricular  septum  on  the 
posterior  aspect  of  the  heart.     {3£useum  of  the  Middlesex  Hospital.) 

are  distributed  by  the  systemic  vessels.  Oesterlin  recorded  a 
case  in  w^hich  a  girl  of  23  years  developed  gangrene  of  the 
right  leg  ;  this  was  amputated,  and  she  died  of  pyaemia.  An 
echinococcus  colony  the  size  of  a  pigeon's  Qgg,  situated  in 
the  wall  of  the  left  auricle,  had  burst  into  the  cavity  of  the 
auricle,  a  piece  of  the  cyst- wall  was  discovered  in  a  thrombus 
in  the  right  common  iliac  artery,  and  an  entire  vesicle  had 
lodged  in  the  deep  femoral  artery. 

A.ltmann  has  recorded  a  case  which  illustrates  the  tragic 
way  in   which   an   echinococcus   colony   of   the   heart   may 


PULMONARY  HYDATIDS  663 

destroy  life.  A  servant-girl  was  gathering  chips  at  a  wood- 
heap  ;  she  fell  down  as  if  in  a  fit,  and  died  within  ten 
minutes.  On  post-mortem  examination  an  echinococcus 
colony  as  big  as  an  orange  was  found  on  the  posterior  aspect 
of  the  left  auricle ;  it  had  ruptured  into  the  auricular  cavity. 
A  daughter -cyst  had  been  conveyed  into  the  left  internal 
carotid  artery  and  blocked  it  at  its  entrance  into  the  cranium. 
A  complete  examination  was  not  permitted. 

When  a  "  colony  "  bursts  into  one  or  other  cavity  on  the 
dextral  side  of  the  heart  the  vesicles  and  fragments  of  mem- 
brane  are  carried  as  emboli  into  the  lungs  (Budd,  Barclay). 

Echinococcus  cysts  seated  in  the  tissues  of  the  heart  are 
said  to  be  primary,  but  the  vesicles  and  membrane  of  a  colony 
may  find  their  way  into  the  heart  as  emboli.  This,  however, 
is  a  very  rare  phenomenon,  and  after  a  careful  search  I 
can  only  refer  to  one — the  classical  observation  reported  by 
Luschke  to  Professor  Leuckart.  A  woman  45  years  of  age 
died  suddenly.  In  the  posterior  border  of  the  liver  there 
was  an  echinococcus  cyst  about  the  size  of  a  child's  head, 
which  had  burst  through  the  walls  and  discharged  some  of 
its  contents  into  the  inferior  vena  cava.  The  daughter-cysts 
had  reached  the  right  chamber  of  the  heart,  and  had  been 
driven  thence  into  the  pulmonary  arteries  and  caused  rapid 
death. 

The  most  impressive  feature  connected  with  the  clinical 
side  of  echinococcus  colonies  in  the  heart  is  the  dramatic 
suddenness  with  which  they  may  cause  death,  but  this  is 
no  novelty  in  connexion  with  grave  cardiac  disorders  of 
any  kind. 

Lungs. — Echinococcus  cysts  occur  in  the  lungs  under 
two  conditions.  (1)  The  cyst — for  it  is  usually  single — may 
be  situated  wholly  within  the  substance  of  the  lung,  and  in 
most  cases  chooses  the  lower  lobe,  especially  of  the  right 
lung ;  or  (2)  it  may  grow  in  the  tissue  immediately  beneath 
the  pulmonary  pleura  and  project  as  an  outgrowth  from  the 
lung  into  the  pleural  cavity.  When  the  cysts  are  small 
they  occasion  little  inconvenience,  but  increasing  in  size 
they  compress  the  lung  and  lead  to  hsemoptysis. 

Apart  from  the  mere  pressure  effects  produced  by  the 
cyst,  it  is  liable  to  rupture  into  the  bronchial  tubes  ;  pieces 


664 


HYDATID   CJY8T8 


of  membrane  and  vesicles  are  coughed  up,  and  indicate  the 
nature  of  the  case.  When  the  cyst  communicates  with  a 
bronchial  tube,  suppuration  of  the  cyst  is  the  inevitable  con- 
sequence. Should  the  cyst  rupture  into  the  pleural  cavity, 
empyema  is  the  usual  result. 

It  is  well  to  bear  in  mind  that,  when  vesicles  and  mem- 
brane are  coughed  up,  it  does  not  necessarily  follow  that  the 
cyst  is  seated  in  the  lung.  Hepatic  cysts  are  sometimes 
evacuated  by  this  route. 


Kidney, 


Brood- 
capsules. 


Ureter. 


Mother-cyst.  Fibrous  capsule. 

Fig.  3.14. — Echinococcus  colony  occupying  the  sinus  of  the  kidney. 
{Museum,  Middlesex  Hospital.) 

Kidney. — Echinococcus  disease  of  this  organ  has  often 
been  recorded.  The  colony  may  lodge  in  the  loose  areolar 
tissue  of  the  renal  sinus  (Fig.  354),  or  grow  immediately 
beneath  the  capsule.  In  each  situation  it  may  attain  a  very 
large  size  and  lead  to  extensive  atrophy  of  the  renal  tissue. 
When  of  small  size  the  cysts  rarely  give  rise  to  trouble  or  even 
inconvenience  during  life,  and  their  presence  is  onl}^  revealed 
in  the  course  of  a  post-mortem  examination. 

There  are  good  reasons  for  believing  that  an  echinococcus 
colony  of  the  kidney  may  rupture  into  the  pelvis  of  the 
organ,  the  fluid  and  vesicles  passing  down  the  ureter,  to  be 


PANCBEATia  HYDATIDS  665 

discharged  by  the  urethra.  This  is,  of  course,  the  most  satis- 
factor}'-  mode  of  termination,  except  perhaps  death  of  the 
parasite  with  subsequent  calcilication. 

In  the  case  of  the  right  kidney,  when  the  cyst- wall 
calcifies,  it  may  form  close  adhesion  to  the  walls  of  the  in- 
ferior vena  cava,  and  make  it  extremely  dangerous  to  stri]^ 
the  capsule  from  the  vein.  In  at  least  one  instance  the  vein 
has  been  torn  in  the  process,  with  a  fatal  result. 

Pancreas. — An  echinococcus  colony  of  the  pancreas  is 
extremely  rare.  In  an  example  under  my  care  the  colony 
was  opened,  emptied,  and  drained,  as  its  enucleation  was 
impracticable.  The  patient,  a  woman,  died  four  weeks  later 
from  hsemorrhage  due  to  ulceration  of  the  inferior  j)an- 
creatico -duodenal  artery.  Post-mortem,  the  dissection  estab- 
lished the  fact  that  the  colony  occupied  the  head  of  the 
pancreas. 

Thyroid  gland. — Echinococcus  cysts  are  rare  in  this 
situation ;  they  have  been  known  to  cause  death  by  bursting 
into  the  trachea. 

Subperitoneal  tissue  and  omenta. — These  are  extremely 
favourable  situations  in  which  the  parasite  can  flourish, 
especially  the  great  omentum,  mesentery,  mesocolon,  and 
the  connective  tissue  of  the  pelvis.  Echinococcus  colonies 
in  the  pelvis  of  women  sometimes  complicate  pregnancy  and 
obstruct  delivery  (Kllstner,  Andrews,  Blacker). 

Birch-Hirschfeld  reported  an  instance  of  an  echinococcus 
cj^st  in  the  cavity  of  the  vermiform  appendix,  which  was 
dilated  to  twice  the  thickness  of  the  thumb.  It  contained 
the  remains  of  membrane  which  presented  under  the  micro- 
scope the  characteristic  lamination.  The  appendix  contained 
a  great  number  of  semitransparent  vesicles,  varying  from  a 
pin's  head  to  a  pea  in  size :  most  of  these  were  sterile.  The 
communication  between  the  appendix  and  the  ciecum  Avas 
obliterated.  The  walls  of  the  appendix  and  its  mucous  mem- 
brane were  atrophied  from  the  pressure  exerted  by  the  cyst, 
and  presented  mosaic-Uke  marks  caused  by  the  pressure  of 
the  vesicles.     The  patient  was  a  man  38  years  of  age. 

Scrotum. — A  man  supposed  to  have  a  hydrocele  as  big  as 
an  emu's  egg  was  tapped  by  Moloney :  it  was  an  echinococcus 
cyst. 


666 


SYDATID   GY8T8 


Connective  tissue  of  the  trunk  and  limbs. — Many 
cases  have  been  recorded  in  which  echinococcus  cysts  have 
been  found  in  the  axilla,  orbit,  posterior  triang'le  of  the  neck, 
etc.  Their  nature  is  rarely  suspected  until  the  swelling  is 
incised. 

Mamma. — Echinococcus  cysts  in  this  gland  are  very 
rare ;  records  of  about  twenty  cases  are  accessible.  The 
patients  were  in  nearly  all  instances  adult  women.  The 
disease  takes  the  form  of  a  slowly  increasing,  painless 
swelling,  which  may  involve  the  whole  breast  or  project  as 


U teTU  s 


Pe.riioiieum 


Eel  1 1 


Fig.  355. — Echinococcus  colonies  in  the  mesometrium.     {After  Freuncl.) 


a  smooth,  elastic,  fluctuating  tumour  from  some  portion  of 
its  circumference.  These  cysts  may  exist  in  the  breast  for 
ten  years  or  longer  without  producing  much  inconvenience  ; 
they  have  been  reported  with  a  capacity  of  twenty  ounces. 
Occasionally  the  cyst  suppurates.  Diagnosis  in  countries 
where  the  echinococcus  is  not  common  is  very  difficult  with- 
out the  assistance  of  an  exploratory  puncture. 

Drawings  of  echinococcus  colonies  of  the  mamma  are 
given  by  Astley  Cooper,  Bryant,  and  others. 

Uterus. — Echinococcus  colonies  have  on  several  occasions 
been  observed  growing  beneath  the  peritoneal  investment  of 


VT^RINE  HYDATIDS 


667 


the  uterus  and  forming  a  tumour  as  large  as  the  patient's 
head  (Fig.  355).  Cysts  of  this  character  chnically  simulate 
ovarian  and  uterine  tumours,  especially  subserous  fibroids 
(Altormyan).  In  one  remarkable  instance  an  echinococcus 
cyst  11  cm.  in  diameter  grew  beneath  the  serous  covering 
of  the  fundus  of  the  uterus  and  opened  into  the  right 
Fallopian  tube,  which  was  greatly  distended,  thrown  into  con- 
volutions, and  filled  with  vesicles  (Moloney).  Freund  has 
published   an  admirable   report  of  some   examples  of  pelvic 


TUBE 


VARY 


Fig.  356. — A  mesosalpinx  with  the  tube  and  ovary  in  transverse  section.     The  ovary 

is  flattened  upon  the  wall  of  an  echinococcus  colony  occupying  the  mesosalpinx. 

*  The  cut  surface  of  the  Fallopian  tube. 

hydatids ;  it  is  the  best  contribution  to  the  literature  of  this 
subject.  His  unique  experience  is  probably  due  to  the  cir- 
cumstance that  his  observations  were  made  in  Silesia — a 
European  region  second  only  to  Iceland  in  the  frequency 
with  which  the  inhabitants  become  infected  by  echinococcus. 
It  is  exceptional  to  find  vesicles  in  the  Fallopian  tubes,  but 
in  a  woman  32  years  of  age  Doleris  found  them  so  stuffed 
with  vesicles  that  they  formed  a  large  tumour  reaching 
above  the  umbilicus.  The  mass  weighed  2  kilogrammes,  and 
consisted  of  the  two  tubes  coiled  upon  themselves  like  small 
intestines,  and  so  elons^ated  that  one  measured  57  and  the 
other  53  cm. 


668  HYDATID   CYSTS 

Ovary. — Neisser  collected  seven  records  of  supposed  hyda- 
tid cysts  of  the  ovary,  but  an  exammation  of  the  original  re- 
ports shows  that  there  was  little  reason  in  most  of  the  cases 
to  class  them  with  hydatids ;  indeed,  one  of  the  cases  was  an 
ordinary  multilocular  ovarian  cyst.  Even  in  the  examples  re- 
corded in  recent  years,  now  that  the  term  "  hydatid  "  is  almost 
restricted  to  the  true  echinococcus  cyst,  the  cases  recorded  as 
"  hydatid  of  the  ovary  "  are  conditions  where  the  colony  has 
grown  primaril}^  in  the  mesometrium,  and  implicated  the 
ovary  secondarily. 

The  specimen  represented  in  Fig.  856  was  removed  by 
the  author  from  a  woman  44  years  of  age.  It  was  as  large 
as  a  turkey's  egg,  and  freely  movable  in  the  belly.  The 
colony  arose  in  the  mesosalpinx,  and  flattened  out  the  ovary. 
As  far  as  could  be  ascertained  at  the  operation,  there  were 
no  other  cysts  in  the  abdomen. 

Testis. — Echinococcus  colonies  have  been  seen  in  the 
scrotum,  but  I  have  never  found  any  record  of  one  within 
the  tunica  albuginea.  ■ 

Brain. — Echinococcus  cysts  occur  in  connexion  with  the 
membranes  of  the  brain ;  the  loose  tissue  of  the  pia  mater  is 
favourable  to  their  growth.  They  are  more  frequent  in  re- 
lation with  the  cerebrum  than  the  cerebellum.  The  pressure 
of  such  cysts  produces  a  bay  in  the  cortex  of  the  cerebrum. 
It  is  often  remarked  by  those  who  have  recorded  examples  of 
intracranial  hydatids  that  the  damage  produced  by  the  cyst 
on  the  brain  is  out  of  proportion  to  the  symptoms  ;  but  the 
same  is  equally  true  of  almost  all  cerebral  tumours.  Hydatid 
cj^sts  of  the  brain  are  nearly  always  sterile,  and  they  are  not 
furnished  with  the  thick  fibrous  capsule  which  surrounds 
them  in  the  liver  and  omentum. 

Bones. — Echinococcus  colonies  are  very  rare  in  bones,  and 
they  seem  to  prefer  the  medullary  cavities  of  long  bones.  The 
variety  found  in  the  bones  of  man  is  that  known  as  Echino- 
coccus multilocular  is,  in  which  there  is  no  mother-cyst,  but 
the  medullary  cavity  of  the  bone  is  occupied  by  a  multitude 
of  vesicles  (Fig.  357).  The  effect  of  these  colonies  on  the 
bone  is  very  extraordinary  ;  they  induce  atrophy  of  its  shaft, 
and  at  length  the  bone  breaks  from  some  trivial  injury.  In 
some  instances  operations  have  been  undertaken  for  the  relief 


Fig.  357. — Echinococ- 
cus  multilocularis 
iu  the  shaft  of  tlie 
humerus ;  from  a 
woman  35  years  of 
age  who  suffered 
amputation  through 
the  shoulder- joint. 
{After  Graham.) 


Fig.  358. — Remnants  of  a  femur  and  tibia 
fenestrated  by  a  colony  of  Echinococciis 
multilocularis.  {Museum  of  the  Royal  College 
of  Surgeons.') 


6G9 


670 


HYDATID   CYSTS 


of  abscesses  supposed  to  be  due  to  necrosis,  and  wlien  the 
bone  has  been  opened  up  vesicles  have  escaped.  When  the 
colon}^  occupies  the  end  of  a  bone  the  vesicles  may  invade 
the  adjacent  joint  (Fig.  358). 

Spine. — Echinococcus  cysts  occur  in  connexion  with  the 
spine  under  three  conditions. 

1.  The  cysts  are  situated  entirely  ivithin  the  canal.  Such 
are  divisible  into  two  sets:  (a)  cysts  lying  inside  the  dural 
sheath,  and  (b)  those  which  grow  in  the  loose  areolar  tissue 
between  the  bone  and  the  dura  mater  (Fig.  359).  The  ma- 
jority belong  to  the  latter  division. 

Schlesenger  tabulated  the   variety  and   position   of  four 


Dura  Mater 


-Cord 


Fig.  359. — Extradural  eclimococcus  cyst  compressing  the  sx^iial  cord  at  the  level 
of  the  third  cervical  vertebra.     (Modified  from  Colman.) 


hundred  tumours  of  the  spinal  canal :  forty-four  were  echino- 
coccus cysts,  five  were  intradural  and  thirty-nine  extradural. 

2.  The  cysts  arise  in  a  vertebra  and  extend  into  the  neural 
canal.  Primary  echinococcus  colonies  of  the  vertebrae  are 
examples  of  E.  onultilocularis   (Fig.    360). 

3.  Echinococcus  colonies  groiving  in  tissues  adjacent  to 
the  spine  inay  involve  the  vertebrcc  and  extend  into  the 
spinal  canal. 

Symptoms  and  diagnosis. — The  localizing  symptoms 
depend  entirely  on  the  situation  of  the  cyst.  For  example, 
when  the  cyst  or  colony  is  in  the  spinal  canal  the  symptoms 


DIAGNOSIS 


671 


will  be  those  common  to  any  tumour  large  enough  to  com- 
press the  spinal  cord  and  produce  paraplegia.  In  the  cranial 
cavity  the  symptoms  are  identical  with  those  produced  by 
any  tumour  which  compresses  the  brain. 

In  the  abdomen,  especially  when  the  cysts  are  connected 
with  the  liver,  the  nature  of  the  swelling  may  be  suspected 
when  it  is  painless  and  slowly  increasing,  and  especially  if 
a  peculiar  vibratory  thrill  is  produced  by  percussing  the 
middle  finger  of  the  left  hand 
when  it  is  laid  firmly  over  the 
tumour. 

When  the  colonies  burst 
into  hollow  viscera  and  the 
characteristic  vesicles  are  dis- 
charged by  the  bowel,  urethra, 
vagina,  trachea,  or  through 
suppurating  sinuses,  then  the 
nature  of  the  disease  is  self- 
evident.  In  countries  where 
hydatid  disease  is  endemic, 
it  is  usual,  in  cases  in  which 
a  tumour  or  swelling  exhibits 
negative  characters,  to  regard 
it  as  an  echinocoecus  cyst. 
More  than  half  the  examples 
of  this  disease  occur  as  sur- 
prises in  the  course  of  surgical 
operations.  To  aid  diagnosis, 
efforts  have  been  made  by 
Welch  and  Chapman  to  ob- 
tain a  precipitin  reaction 

Treatment. —  This  is  al- 
ways surgical,  and  the  parti- 
cular method  of  carrying  it  out  varies  with  the  situation  ot  the 
cyst.  When  they  hang  as  big  as  apples  from  the  omentum, 
it  is  only  necessary  to  expose  the  cysts  through  an  incision  in 
the  belly-wall,  ligature  the  pedicle,  and  remove  them.  In 
many  cases  they  are  firmly  adherent  to  surrounding  struc- 
tures. In  these  circumstances  the  fibrous  capsule  should  be 
freely   incised   and   the  mother-cyst  enucleated ;   the  empty 


Fig 


360. — Echinocoecus  muUilocularin 
in  the  seventh  cervical  vertebra. 
[Museum  of  St.  George'' s  Sospitcd.^ 
{After  Bennett.) 


672  HYDATID    CYSTS 

capsule  rarely  gives  trouble.  Suppurating  cysts  demand  free 
incision  and  drainage.  In  removing  colonies  it  is  wise  to 
avoid  soiling  the  edges  of  the  wound  with  brood-capsules, 
as  they  may  give  rise  to  cysts  of  some  size  in  the  cicatrix. 

In  the  case  of  the  liver,  echinococcus  colonies  treated  by 
incision,  enucleation  of  the  capsule,  and  free  drainage  give 
but  .little  trouble.  Great  care  should  be  taken  thoroughly  to 
remove  the  mother-cyst,  for  decomposition  of  this  tissue  when 
left  is  a  source  of  grave  danger.  All  meddling  methods — as 
punctures  with  trocars,  aspiration,  and  electrolysis — cannot 
be  too  strongly  condemned. 

Echinococcus  cysts  in  the  lungs  require  to  be  treated  on 
the  principles  of  empyema,  and  in  this  situation  Lendon 
particularly  insists  on  the  necessity  of  removing  the  mother- 
cyst.  The  contents  of  dead  colonies  are  sometimes  so  firm 
that  they  require  removal  with  a  scoop.  When  the  cyst-wall 
is  calcified  it  often  leads  to  a  persistent  sinus. 

In  the  case  of  bones  the  treatment  consists  of  incision, 
evacuation  of  vesicles,  and  drainage.  Exceptionally,  when 
the  bone  is  seriously  damaged,  fractured,  or  a  large  joint  is 
invaded,  amputation  has  been  found  a  necessity. 

Echinococcus  cysts  within  the  cranium  have  been  local- 
ized, exposed  by  trephining,  and,  after  evacuating  the  fluid, 
the  cyst  has  been  successfully  extracted  (Yerco,  Rennie  and 
Crago,  Mills  and  McCormick). 

Echinococcus  cysts  in  the  spinal  canal  have  been  suc- 
cessfully submitted  to  surgery  (Tytler  and  Williamson).  The 
difficulty  of  localizing  and.  treating  some  of  these  cases  is 
well  shown  by  a  case  recorded  by  Stewart  McKay. 

Single  echinococcus  cysts  and  colonies  give,  as  a  rule, 
admirable  results  when  treated  surgically,  but  in  cases  where 
the  patient  suffers  from  a  general  infection  the  disease  is 
very  inveterate,  demands  much  persistence  on  the  part  of 
the  surgeon,  and  calls  for  great  courage  and  fortitude  on 
the  part  of  the  patient. 

In  a  woman  with  general  dissemination  of  hydatids  in 
the  omentum  and  subperitoneal  tissue,  I  removed  numerous 
large  echinococcus  colonies  on  seven  occasions  in  nineteen 
years.  She  remains  in  apparently  good  health.  Between 
the  second  and  third  operations  she  successfully  conceived. 


HYDATID    CYSTS  673 

Altmann,  "  Hydatid  of  Heart ;  rupture  into  left  auricle  and  plugging  of  left 
carotid  artery." — Intercolonial  Med.  Journ.  of  Australia,  1902,  p.  573. 

Andrews,  R.  H.,  "  A  Case  in  which  Pregnancy  was  complicated  by  the  presence 
of  a  Hydatid  Cyst  in  the  Pelvis."— /c»?/r«.  of  Vhstet.  and  Gyn.,  1908, 
xiv.  333. 

Barclay,  J.,  "A  Case  of  Hydatids  of  the  Heart  and  l^wag^"— Glasgow  Med. 
Journ.,  N.S.,  1867,  i.  426. 

Bryant,  T.,  "  Diseases  of  the  Breast,"  1887,  Plate  viii.,  Figs.  3  and  4. 

Budd,  W.,  "Hydatid  Tumour  in  Apex  of  Right  Ventricle  of  the  Heart."— 

Trans.  Path.  Soc,  1859,  x.  80. 
Colman,  W.  S.,  "Hydatid  Cyst  of  the  Spinal  Canal,  causing  Paraplegia."— 

St.  Thomas's  Hasp.  Repts.,  1899,  xxviii.  361. 

Cooper,  Sir  Astley,  "  Diseases  of  the  Breast,"  1829,  Plate  ix. 
Evans,  H.  R.,  "Case  in  which  a  Cyst  containing  Hydatids  was  found  in  the 
substance  of  the  Heart." — Med.-Chir.  Trans.,  1832,  xvii.  507. 

Finsen,  Jon,  "  Les  Echinocoques  en  Islande." — Arch.  Gen.  de  Med.,  1869, 
xiii.  23. 

Freund,  W.  A.,  "  Gynakologische  Klinik,"  Strasburg,  1885,  i.  203. 

Graham,  James,  "Hydatid  Disease,"  1891,  pp.  134,  137. 

Krabbe,  "  Recherches  Helminthologiques  en  Danemark  et  en  Islande,"  1866. 

Klistner,  "  Kaiserschnitt  wegen  eines  Echinokokkus  imBecken." — Zentralbl.  f. 

Gyn.,  1907,  xxxi.  1390. 
Lendon,  A.  A.,  "  Clinical  Lectures  on  Hydatid  Disease  of  the  Lungs,"  1902. 
Leuckart,  R,  "  The  Parasites  of  Man,"  1886. 
McKay,  W.  J.  Stewart,  Australian  Med.  Gaz.,  Feb.  20,  1906. 
Mills  and  McCormick,  Australian  Med.  Journ.,  Nov.  1904. 
Moloney,   "  Hydatid  of   Pelvis   opening   into   the  Right   Fallopian   Tube."— 

Australian  Med.  Journ.,  1879,  i.  478. 
Moxon,  W.,  "  Hydatid  of  the  Heart  obliterating  by  its  pressure  the  Coronary 

Sinus."— I'raws.  Path.  Soc,  1869-70,  xxi.  99. 
Muskett,  P.  E.,  "  Unusual  Site  for  Hydatid  Cyst;  an  addition  to  the  recognized 

varieties  of  intrascrotal  disease." — Australasian  Med.  Gaz.,  1886-7,  vi.  57. 
Oesterlin,   Otto,  "Ueber  Echinococcus  an  Herzen." — Virchow's  Arch,  f.path. 

Anat.,  1868,  xlii.  404. 
Peacock,  T.  B.,  and  Wale  Hicks,  J.,  "  Hydatids  in  Liver,  Spleen,  Right  Kidney, 

Omentum,  Lungs,  and  Heart." — Trans.  Path.  Soc,  1863-64,  xv.  247. 

Rennie  and  Crago,  Australian  Med.  Gaz.,  1902,  p.  547. 

Schlesenger,  Beit.  z.  Klinik  der  Riockenmark  und  Wirhelttimoren,  Jena,  1898. 

Treves,  Sir  Frederick,  "  Peculiar  Mode  of  Rupture  of  a  Hydatid  Cyst." — 
Trans.  Clin.  Soc,  1887-88,  xxi.  82. 

Tytler,  P.,    and  Williamson,  R.  P.,  "  Spinal    Hydatid  Cysts  causing    severe 
Compression  Myelitis." — Brit.  Med.  Journ.,  1903,  i.  301. 
2  R 


674  HYDATID    CYSTS 

Verco,    Dr.,    "Intercolonial    Medical    Congress    of   Australasia:     Section    of 
Surgery  ;  Discussion  on  Hydatids." —  Brit.  Med.  Journ.,  1892,  ii.  1066. 

Virchow,  Rudolph,  "  Die  multiloculare  ulcerirende  Echinokokkengeschwulst 
der  Leber." — Verh.  d.phys.  med.  Ges.  z.  Wiirzhurg,  1856,  vi.  84. 

Virchow,  Rudolph,  "  On  Multilocular  Hydatid." — Australian  Med.  Jouroi.,  1884, 
p.  171. 

Welch,  D.   A.,  and  Chapman.  H.    G.,  "The   Precipitin  Reaction   in   Hydatid 
Disease."— Zawce^,  1908,  i.  1338,  and  1909,  i.  1103. 

Ziegler,  E.,  "  Tasnia  Echinococcus  ]\Iultilocularis." — Lehrh.  d.  allg.  Path.  u.  path. 
Anat.,  1905,  i.  762. 


INDEX 


Aoardiacs,  428 
Accessary  adrenals,  102 

thyroids,  472 

. tragus,  484 

Adenoeele,  248,  252 
Adenoma,  248 

cystic,  248,  252 

fibro-,  250 

of  breast,  248,  250 

of  intestine,  249 

•  of  liver,  345 

of  ovary,  488,  494,  504 

of  palate,  92 

of  pituitary  body,  317 

of  stomach,  249 

of  testis,  539 

of  thyroid,  249,  313 

■  of  uterus,  373 

sebaceous,  309 

Adeno-myoma,  375 
Adeno-sareoma,  248 
Adrenal  tumours,  106 

■ in  adults,   109 

in  children,   106 

Adrenals,  accessary,  102 

Age-distribution  of  tumours,  9 

Age-incidence  of  fibroids,    195 

Albinism,  110 

Alimentary  canal,  sarcoma  of,  72 

Alkaptonuria,   114,  120 

AUantois,  cysts  of,  599 

Amorphous  acardiacs,  428 

Ampulla  of  Vater,  cancer  of,  354 

Anaplasia,  284 

Aneurysm  by  anastomosis,  159 

cirsoid,  159 

Angeioma,  156 

cavernous,  157 

of  brain,  161 

of  breast,  157 

of  conjunctiva,  157 

of  heart,   158 

of  labium,  157 

of  larynx,  158 

of  lip,  157 

of  liver,  159 

of  muscles,  158 

of  subperitoneal  tissue,  159 

of  synovial  membrane,  159 

of  tongue,  158 

plexiform,  159 

simple,  156 


Angeio-sarcoma,  410 

Anidian  monsters,  428 
Antenatal  hydronephrosis,  577 
Antrum,  carcinoma  of,  325 
Anus,  carcinoma  of,  343 
Appendices  epiploicse,   16 
Appendix  {see  Vermiform  appendix) 
Archoplasmic  vesicles,  282 
Atrophic  cancer,  260 
Auricles,  cervical,  477 

sebaceous  cysts  of,  484 

Auricular  dermoids,  481,  483 

fistulse,  481,  482 

Autosite,  422 

Axial  rotation  of  fibroids,  193 

of  ovarian  tumours,  529 


Bartholin's  gland,  carcinoma  of,  370 
Bile-ducts,  carcinoma  of,  353 
Biologic  theory  of  cancer,   281 
Bird's-eye  inclusions  in  carcinoma,  282 
Bistournage,  532 
Bladder,  carcinoma  of,  363 

diverticula  of,  612 

myoma  of,  59 

sacculated,  612 

villous  papilloma  of,  238 

Blood-supply  of  sarcomas,  62 
Bone,  carcinoma  (secondary)  of,  269 

chondroma  of,  26 

hydatid  cysts  of,  668 

lipoma  of,  21 

myeloma  of,  45 

osteoma  of,  34,  37 

sarcoma  of,  77 

Brain,  angeioma  of,   161 

glioma  of,   148 

hydatid  cysts  of,  668 

•  neuroma  of,  131 

Branchial  fistula,  474 

Brawny  arm  in  carcinoma  of  breast, 

297 
Breast,  adenoeele  of,  248 

adenoma  of,  248,  250 

angeioma  of,   157 

carcinoma  of,  287,  292 

cysts  of,  253,  303 

duct-carcinoma  of,  303 

duct-papilloma  of,  303 

■ endothelioma  of,  410 

hydatid  cysts  of,  666 


675 


676 


INDEX 


Breast,  sarcoma  of,  75 

Bronchocele,  313 

Brood-capsules,  653 

Bunion,  625 

Burrowing  tendencies  of  sarcoma,  66 

Bursse,  adventitious,  624 

sarcoma  of,  71 

subtendinous,  624 


Caecum,  carcinoma  of,  337 
Calcification  of  lipomas,  14 

of  sarcomas,   69 

Calculus  of  salivary  glands,  570 
Cancer  [see  Carcinoma) 
Canceroderms,  119 
Carcinoma      (cancer),     acinous     (of 
breast),  292 

arising  in  innocent  tumours,  10 

atrophic,  260 

biologic  theory  of,  281 

causes  of,  275 

colloid,  259,  332 

contact-transference,  272 

countryman's,  319 

degeneration  of,  259,  332 

dissemination  of,  263 

duct-,  303 

emboli  in,  266 

embryonic  theory  of,  275 

en  cuirasse,  296 

gall-stones  in  relation  to,  349 

gland-,  258 

gland-infection  in,  260 

■ heredity  in,  273 

•  infection  of,  270 

inoperable,  287,  291 

lymphatics  of,  260 

melano-,  117 

of  ampulla  of  Vater,  354 

of  antrum,  325 

of  anus,  343 

of  Bartholin's  gland,  370 

of  bile-ducts,  353 

of  bladder,  363 

of  bone,  269 

of  breast,  287,  292 

of  caecum,  337 

• •  of  cheek,  322 

■ of  clitoris,  369 

of  conjunctiva,  256 

of  Cowper's  gland,  367 

of  Fallopian  tube,  399 

of  fauces,  322 

of  gall-bladder,  348 

of  gum,  322 

■ — —  of  hepatic  duct,   353 

of  intestine,  336 

of  jaw,  322 


Carcinoma  (cancer)  of  kidney,  361 

of  labium,  368 

of  larynx,  7,  325 

of  lip,  319 

of  liver,  346 

of  lung  (secondary),  266 

of  oesophagus,  328 

of  ovary,  522 

(secondary),  524 

of  palate,   322 

of  pancreas,  355 

• of  penis,  366 

of  pharynx,  322 

of  piima,  256 

of  prostate,  269,  365 

of  rectum,  336,  342 

of  scars,  256 

of  scrotum,  365 

of  sebaceous  glands,  311 

of  stomach,  330 

of  testis,  537 

■ of  thyroid,  315 

of  tongue,  321 

of  tonsil,  322 

of  ureter,  363 

of  urethra,  364 

of  uterus,  body,  389 

with  fibroids,  395 

neck,  380 

with  fibroids,  393 

of  vagina,  369 

of  vermiform  appendix,  337 

of  vulva,  368 

oophorectomy  in,  280 

parasitic  theory  of,  278 

parenchyma  of,  255 

peritoneal  infection  in, 

permeation  in,  267 

recurrence  of,  301 

rodent,  311 

squamous-celled,  255 

stroma  of,  255 

sweep's,  255 

terminal  infections  in, 

theory  of,  biologic,  281 

embryonic,  275 

parasitic,  278 

trauma  in  relation  to, 

treatment  of,  287 

varieties  of,  254 

withering,  260 

X-ray,  257 

Cartilage-containing  tumours,  26,  55, 
546 

Cartilaginous  tumours  (see  Chon- 
droma) 

Cavernous  lymphangeioma,   163 

naevus,   157 

Cementoma,  215 


265 


268 


277 


INDEX 


677 


Cervical  fibroids,  173 

fistulae,  lateral,  474 

median,  468 

teeth,  559 

Cervix,  erosion  of,  373 
Chsetodon,  41 
Cheek,  cancer  of,  322 
Chloroma,  121 
Chondroma,  26 

calcification  of,  26 

of  bone,  26 

of  joints,  29 

of  larynx,  30 

of  nose,  30 

of  pelvis,  28 

ossification  of,  26 

Chorion-epithelioma,  9,  415 

benignum,  417 

in  teratoma,  420 

malignum,  419 

Choroid  plexus,  papilloma  of,  241 
Chromatophores,  112 
Chyle-cysts,  609 
Cicatrix,  carcinoma  of,  256 

horns  of,  242,  245 

Ciliated  epithelium  in  ovarian  cysts, 

491 
Cirsoid  aneurysm,  159 
Classification  of  tumours,  4 
Clavicle,  sarcoma  of,  86 
Clitoris,  carcinoma  of,  369 
Coccygeal  sinus,  444 
Colloid    degeneration    in    carcinoma, 

259,  332 
Colon,  carcinoma  of,  341 

lipoma  of,   18 

•  teratoma  of,  437 

Composite  odontoma,  222 
Compound  follicular  odontoma,  216 
Conglomerate  fibroids,  169 
Conjoined  twins,  422 
Conjunctiva,  angeioma  of,   157 

carcinoma  of,  256 

dermoids  of,    127 

lipoma  of,   17 

moles  of,   127 

Connective-tissue  tumoiirs,  12 

Corneal  cysts,  464 

Corpus  luteum,  507 

Cowper's  gland,  carcinoma  of,  367 

Cryptophthalmos,  129 

Cutaneous  horns,  242 

Cystic  adenoma,  248,  252 

disease  of  testis,  538 

Cysts,  allantoic,  599 

bursal,  624 

chyle-,  609 

dental,  230 

dentigerous,  212 


Cysts,  dermoid  (of  ovary),  492 

Gartnerian,  518 

hydatid  {see  Hydatid  cysts) 

implantation-,  462 

involution-,  303 

lutein  (see  Lutein  cysts) 

Mullerian,  600 

neural,  629 

of  breast,  253,  303 

of  cornea,  464 

of  eyeball,  573 

of  eyelid  (dacryops),   573 

of  finger,  462 

of  gall-bladder,  569 

of  hyaloid  canal,  573 

of  iris,  464 

of  joints,  620 

of  kidney  (congenital),  586 

of  lachrymal  gland,  573 

■  of  liver,  564 

multiple,  565 

single,  566 

of  neck,  164,  476 

of   ovary,   488,    491,  494,     504, 

535 

of  pancreas,  571 

of  pharynx,  612 

of  salivary  glands,  570 

of  testicle,  538 

of  thyroid  gland,  314 

of  umbilicus,  594 

of  urachus,  599 

of  vermiform  appendix,   564 

oophoronic,  487 

papillomatous,  of  breast,  303 

of  ovary,  509 

of  thyroid,  314 

parovarian,  514 

pseudo-,  611 

retention-,  563 

sebaceous,  307 

synovial,  620 

teno-synovial,  622 

vitello-intestinal,  594 

Cytological  transformations  of  malig- 
nant tumours,  281 


Dacryops,  573 
De  Morgan  spots,   119 
Deeiduoma,  415 

Degeneration-changes    in    carcinoma, 
259 

in  fibroids,   199 

in  sarcoma,  69 

Demodex  folliculorum,  307 
Dental  cysts,  230 
Dentigerous  cysts,  212 
Dermatitis,  X-ray,  257 


678 


INDEX 


Dermoid  pterygium,   127 
Dermoids,  auricular,  483 

of  back,  442 

of  conjunctiva,  127 

of  dura  mater,  459 

of  face,  448,  455 

of  inguinal  canal,  446 

of  labium,  446 

of  lung,  434 

of  neck,  447,  468 

of  nose,  457 

of  orbito-nasal  fissure,  455 

of  ovary,  487,  492,  495,  535 

of  pinna,  483 

of  rectum,  437 

of  sacrum,  429 

of  scalp,  459 

of  scrotum,  445 

of  sternum,  447 

of  testicle,  445,  542 

of  thorax,  434,  447 

of  tongue,  467 

sequestration-,  442 

•  tubulo-,  442 

Dichotomy,  424 
Digits,  bursse  of,  625 

chondroma  of,  26 

cysts  of,  462 

lipoma  of,  13 

melanoma  of,   115 

Dissemination  of  carcinoma,  263 

of  sarcoma,  63 

Distribution  of  sarcoma,  69 
Diverticula,  intestinal,  611 
laryngeal,  618 

oesophageal,  615 

pharyngeal,  612 

synovial,  622 

tracheal,  615 

vesical,  612 

Duct  of  Gartner,  487,  515 

cysts  of,   518 

Dura-endothelioma,  410 
Dura  mater,  dermoids  of,  459 
•  endothelioma  of,  410 


Ecchondrosis,  articular,  29 

larjmgeal,  29 

nasal,  30 

Echinococcus    disease    (see    Hydatid 

cysts) 
Echinococcus  mailtilocularis,  654 
Egg-shell  crackling,  48 
Embryoma,  malignant,  505 

ovarian,  487,  492,  502 

testicular,  542 

Embryonal      rudiment     in     ovarian 

dermoids,  503 


Embryonal    rudiment    in   teratoma 

of  testis,  542 
Embryonic  theory  of  cancer,  275 
Endothelioma,  405 

of  breast,  409 

of  dura  mater,  410 

of  gum,  405 

of  omentum,  410 

of  ovary,  523 

•  of  salivary  glands,  405 

•  of  skin,  410 

of  uterus,  410 

Environment  in  relation  to  tumours,  4 
Epignathus,  436 
Epithelial  balls,  497 

infection  in  ovarian  embryomas, 

505 

odontoma,  211 

Epoophoron,  487 
Erosion  of  cervix,  373 
Eustachian  pouches,  617 
Evolution  of  central  nervous  system, 

649 
Exostoses,  37 

from  inflammatory  products,  41 

subungual,  41 

Eyeball,  carcinoma  of,  117 

cysts  (of  cornea)  of,  464 

(of  iris)  of,  464 

glioma  of,  151 

melanoma  of,  116 

Eyelid,  coloboma  of,  128 

cysts  (dacryops)  of,  573 

dermoids  of,  455 

nsevi  of,   157 


Face,  angeioma  of,   156 

dermoids  of,  448,  455 

mandibular  tubercle  of,  451 

■ moles  of,   126 

Fallopian  tube,  carcinoma  of,  399 

•  papilloma  of,  398 

pseudo-cysts  of,  627 

Fatty  hernise  of  linea  alba,   16 

tumour  (see  Lipoma) 

Fauces,  carcinoma  of,   322 
Feet,  sarcoma  of,  88 
Femur,  periosteal  sarcoma  of,  78 
Fibro-adenoma  of  breast,  250 
Fibro-cystic  tumour,  180 
Fibroids,  age-incidence  of,   195 

axial  rotation  of,  193 

carcinoma  of,  393,  395 

changes  (secondary)  in,   180 

clinical  characters  of,  206 

conglomerate,  169 

degeneration  of,  199 

extrusion  of,  189 


INDEX 


679 


Fibroids,  growth  of,  186 

impaction  of,   192 

incarceration  of,   192 

interstitial,   169 

intestinal  obstruction  by,  193 

intracervical,   173 

intramural,  168,   192 

latent,  172 

lymphatics  in,   185 

malignant  changes  in,   184 

menopause  and,  203 

menstruation  and,   195 

necrobiosis  of,   183 

of  cervix  uteri,   173,   192 

(intracervical),     173, 

190 

of  malformed  uterus,   178 

of  mesometrium,  176 

of  ovarian  ligament,   177 

of  ovary,  520 

of  round  ligament,  177 

of  utero -sacral  ligament,   178 

pregnancy  with,  198 

rate  of  growth  of,  186 

red  degeneration  of,   183,  201 

secondary  changes  in,   180 

septic  infection  of,  188,   199 

structure  of,  180 

submucous,   169 

subserous,   171,   192 

treatment  of,  207 

tubal  pregnancy  with,  203 

uterine,   168 

Fibro-myoma,  168,  181 
Fibrous  odontoma,  215 
Fistula,  auricular,  482 

branchial,  474 

cervical,  468,  474 

•  coccygeal,  444 

nasal,  457 

Fleshy  j)olypus  of  womb,   170 
Follicular  odontoma,  212 
Functionless  ducts,  594 


Galaetocele,  253 

Gall-bladder,  carcinoma  of,  348 

cystic,  569 

mucocele  of,  569 

Gall-stones,  cancer  and,  349 
Ganglion,  compound,  623 

simple,  622 

Ganglionic  neuroma,  131 
Gartner's  duct,  487,  515 

cysts  of,  518 

Gastric  lipoma,   17 

General  thyroid  malignancy,  104,  316 

Gland-cancer,  258 

Glandular  organs,  sarcoma  of,  95 


Glioma,  134,  148 

of  brain,   148 

of  retina,   151 

of  spinal  cord,   153 

Gliomatous  disease,  9 
Gonads,  550 
Goundou,  41 
Gum,  carcinoma  of,  322 

endothelioma  of,  405 

sarcoma  of,  90 

Guttural  pouches  of  horses,  616 


Haematocele  of  tunica  vaginalis,  603 
Haemendothelioma,  405 

Hsemorrhage  with  fibroids,   187 

Hand,  lipoma  of,   13 

sarcoma  of,  88 

Heart,  angeioma  of,  168 

hydatids  of,  660 

lipoma  of,  21 

Hepatic  duct,  carcinoma  of,  353 

Heredity  in  cancer,  273 

Hernial  lipoma,  16 

Heterotopic  teeth,  553 

Hibernating  gland,  20 

Hodgkin's  disease,  53 

Homogentisinic  acid,  120 

Horned  men  of  Ivory  Coast,  40 

Horns,  cicatrix-,  242,  245 

cutaneous,  242,  244 

in  ovarian  dermoids,  496 

nail-,  242,  246 

sebaceous,  242 

treatment  of,  246 

wart-,  242,  244 

Hyaloid  canal,  cysts  of,  573 

Hydatid  cysts,  652 

of  bone,  668 

of  brain,  668 

■-  of  breast,  666 

of     connective     tissue     of 

limbs  and  trunk,  666 

of  heart,  660 

of  kidney,  664 

of  liver,  658 

of  lungs,  663 

of  omentum,  665 

of  ovary,  668 

of  pancreas,  665 

of  scrotum,  665 

•  of  spine,  670 

of  testicle,  668 

of  thyroid,  665 

of  uterus,  666 

of  vermiform  appendix, 665 

disease,  geographical  distribu- 
tion of,  656 

rash  of,  655 


680 


INDEX 


Hydatid  disease,  symptoms  and 
diagnosis  of,  670 

treatment  of,  671 

zoological  distribution   of, 

656 

mole,  417 

Hydramnion,  629 

Hydrocele,  congenital,  605 

encysted,  of  cord,  603 

of  testis,  550 

funicular,  606 

of  canal  of  Nuck,  606 

of  fourth  ventricle,  634 

of  hernial  sac,  606 

of  tunica  vaginalis,  602 

omental,  609 

ovarian,  607 

■ rupture  of,  605 

treatment  of,  606 

Hydrocephalus,  629,  646 

Hydrocystoma,  238 

Hydrometra,  564 

Hydronephroma,  102 

Hydronephrosis,  564,  575 

antenatal,  577 

bilateral,  575 

■ ■  intermitting,  581 

unilateral,  579 

Hydroperitoneum,  511 

Hydrosalpinx,  609 

Hypernephroma,  102 

Hypertrichosis,  645 


Ileum,  imperforate,  597 

septate,  597 

Impaction  of  fibroids,   192 
Imperforate  hymen,  578 

ileum,  597 

pharynx,  613 

■ urethra,  578,  589,  591 

Implantation-cysts,  462 
Inadequacy  of  ureter,  582 
Infant  Hercules,  107 
Infective  granuloma,   1 
Infiltrating  properties  of  sarcoma,  64 
Inguinal  canal,  dermoids  of,  446 
Innominate  bone,  sarcoma  of,  87 
Inoperable  cancer  and  its  treatment, 

287,  291 
Interdigital  pouch,  445 
Intermandibular  fissure,  452 
Intermuscular  lipoma,  19 
Interstitial  fibroids,   169 

intestinal      obstruction 

with,   193 
Intestinal  obstruction  by  fibroids,  193 
Intestine,  adenoma  of,  249 
carcinoma  of,  336 


Intestine,  diverticula  of,  61] 

lipoma  of,   17 

sarcoma  of,  73 

Intra-abdominal  teratoma,  433 
Intracervical  fibroids,   173 
Intracranial  teratoma,   435 
Intracystic  warts,  238 
Intradural  lipoma,  22 
Intramural  fibroids,   168 
Intramuscular  lipoma,  21 
Intra-ocular  melanoma,  116 
Intrathoracic  teratoma,  434 
Involution -cysts  of  breast,  303 
Iris,  cysts  of,  464 
melanoma  of,   116 


Jaundice  in  carcinoma  of  pancreas,  357 
Jaw,  carcinoma  of,  322 

osteoma  of,  34,  39 

■ sarcoma  of,  89 

Joints,  chondroma  of,  29 

cysts  of,  620 

lipoma  of,  18 

loose  bodies  of,  29,  30 


Kidney,  carcinoma  of,  361 

congenital  cystic,  586 

hydatids  of,  664 

hydronephrosis  of,  564,  675 

papilloma  of,  239 

rotation  of,  579 

sacculated,  584 

sarcoma  of,  96,  101 

Kobelt's  tubes,  515 
Kraurosis  vulvae,  368 


Labium,  angeioma  of,   157 

carcinoma  of,  368 

dermoids  of,  446 

lipoma  of,   16 

Lachrymal  gland,  dacryops  of,  573 
Langhans'  layer,  415 
Laryngocele,  618 
Larynx,  angeioma  of,   158 

carcinoma  of,  7,   325 

extrinsic,  326 

intrinsic,  325 

chondroma  of,  30 

diverticula  of,  618 

lipoma  of,  5,   17 

• neuroma  of,  146 

papilloma  (wart)  of,  237 

Latent  fibroids,   172 
Leio-myoma,  60 
Leucoderma,   1 10 
Leukaemia,  53 


INDEX 


681 


Leukoplakia,  321 
Leukoplakic  vulvitis,  368 
Liability     of     different     organs 

tumours,  3 
Lip,  angeioma  of,   157 

carcinoma  of,  319 

lipoma  of,   17 

Lipoma  arborescens,  18 

calcified,   14 

.  clinical  features  of,  23 

hernial,   16 

intermuscular,  19 

intradural,  22 

intramuscular,  21 

meningeal,  22 

nasi,   138 

of  bones,  21 

of  broad  ligament,   16 

of  colon,   18 

of  conjunctiva,  17 

of  fingers,   13 

of  foot,   13 

of  hand,   13 

of  heart,  21 

of  hernial  sac,   16 

of  intestine,   17 

of  joints,  18 

of  labium,  16 

of  larynx,  5,  17 

of  lip,  17 

of  meninges,  22 

of  mesometrium,  16 

of  muscles,  19 

. of  neck,  14 

of  nerves,  22 

of  pa,lm,  13 

of  scalp,   13 

of  scrotum,   16 

of  sole,  13 

of  spermatic  cord,  16 

of  spinal  cord,  22 

of  stomach,  17 

of  tongue,  19 

parosteal,  21 

subcutaneous,   12 

submucous,   17 

subperitoneal,   16 

subpleural,  17 

subserous,  15 

subsynovial,  18 

treatment  of,  24 

Liver,  adenoma  of,  345 

angeioma  of,   159 

carcinoma  of,  346 

cysts  of,  564 

hydatids  of,  658 

Loose  bodies  in  hydroceles,  605 

in  joints,  29,  30 

cartilages,  29,  30 


I    Lung,  carcinoma  (secondary)  of,  266 

dermoids  of,  434 

to    I hydatids  of,  663 

Lutein  cysts,  507 

in     relation     to     hydatid 

mole,  417 
Lymphadenoma,  53 
Lymphangeioma,  162 

cavernous,   163 

lingual,  162 

Lymphatic  cyst,   164 

nsevus,   162 

Lymphatics  of  carcinoma,  260 

of  fibroids,  185 

Lymph-gland  infection  in  carcinoma, 

260 
Lympho-sarcoma,  53,  547 


Macroglossia,  143,  162 
Macrostoma,  451 

Malignant  transformation  of  fibroids, 
184 

of  tumours,  10 

tumours,   cytologic  transforma- 
tions of,   281 
inoperable,  287 

relation  of  trauma  to,  277 

Mamma-  (see  Breast) 

Mandible,  osteoma  of,  34 

sarcoma  of,  89 

Mandibular  recesses,  451 

tubercles,  451 

Masked  spina  bifida,  644 

Mastoid  teeth,  556 

Maxilla,  osteoma  of,  40 

sarcoma  of,  89 

Meckel's  diverticulum,  596 

Median  cervical  fistula,  468 

Melanin,   113 

Melanism,   110 

Melano-carcinoma,  117 

Melanoma,  6,  112 

of  eyeball,   116 

Melanosis,  110 

Melanotic  sarcoma,  112 

Melon-seed  bodies,  622,  623 

Meningeal  lipoma,  22,   649 

Meningocele,  634,  641 

Meningo-encephalocele,  634 

Meningo-myelocele,  640 

Menopause  in  fibroids,   203 

Menstruation  and  fibroids,   195 

Mesentery,  chyle-cysts  of,  609 

lipoma  of,   16 

Mesometrium,  fibroids  of,   176 

lipoma  of,   16 

Mesonephros,  514,  537,  588 

Metaplasia,  284 


682 


INDEX 


Microstoma,  451 
Moles,  114,  123 

conjunctival,  127 

Molluseum  fibrosum,  134,  136 

Mouse-tumours,  malignant,  285 
Mucocele,  569 

Miillerian  ducts,  cysts  of,  600 
Multilocular  cystic  epithelial  tumours, 
212 

cysts  of  ovary,  488 

Multiple  neuromas,  134,   146 
Muscles,  angeioma  of,  158 

lipoma  of,  19 

sarcoma  of,  70 

Myelocele,  639 
Myeloid  sarcoma,  45 
Myeloma,  9,  45 

clinical  characters  of,  47 

treatment  of,  48 

Myoma,  59 

■ of  alimentary  canal,  59 

of  bladder,  59 

uterine,  168 

Myo-sareoma,  55 

Myosotis  ossificans,  41 

Myxoma,  58 

Myxo-sarcoma  of  omentum,  332 


Naevo-lipoma,  14 
Naevus  (see  Angeioma) 

pilosus,  123 

spUosus,  114,  123 

Nail-horns,  242,  246 
Nasal  chondroma,  30 

dermoids,  457 

polypi,  59 

Naso-pharyngeal  tumours,  89 
Neck,  auricles  of,  477 

•  cysts  of,  164,  476 

dermoids  of,  447,  468 

fistulas  of,  468,  474 

lipoma  of,   14 

sebaceous  cysts  of,  476 

teratoma  of,  561 

Necrobiosis  of  fibroids,  183 
Necrosis  of  ovarian  tumours,  532 

of  sarcoma,  69 

Nerves,  lipoma  of,  22 

neuroma  of,   130,   143,  144,  146 

— —  sarcoma  of,  70,   134 
Neural  cysts,  629 
Neuro-fibromatosis,  134 
Neuro-lipoma,  22 
Neuroma,  130 

ganglionic,  131 

of  facial  nerve,  143 

of  hypoglossal  nerve,   143 

of  laryngeal  nerve,  146 


Neuroma  of  lingual  nerve,   143 

of  musculo-spiral  nerve,  144 

of  occipital  nerve,   143 

of  trigeminal  nerve,   143 

plexiform,   134,   140 

Nose  (see  Nasal) 

Nuck,  hydrocele  of  canal  of,  606 


Obsolete  canals,  466,  594 
Ochronosis,  120 
Odontoma,  211 

clinical  characters  of,  228 

composite,  222 

compound  follicular,  216 

epithelial,  211 

fibrous,  215 

follicular,  212 

radicular,  218 

treatment  of,  230 

(Esophagus,  carcinoma  of,  328 

diverticula  of,  615 

myoma  of,  59 

Omentum,  endothelioma  of,  410 

hydatid  cysts  of,  665 

hydrocele  of,  609 

in  cancer  of  stomach,  332 

Oophoron,  486 

cysts  of,  487 

Operculum,  478 

Optic  nerve,  sarcoma  of,   150 

Orbito-nasal  fissure,  dermoids  of,  455 

Osseous  tumours,  34 

Ossification  of  tendons  at  attachment, 

38 
Osteoma,  34 

cancellous,  37 

clinical  characters  of,  41 

compact,  34 

facial,  34,  39 

of  auditory  meatus,  36 

of  frontal  sinus,  35 

of  mandible,  34 

of  maxilla,  40 

of  orbit,  35 

treatment  of,  42 

Ovarian  adenoma,  488,  494,  504 

carcinoma,  524 

cysts,  multilocular,  488,  494,  504 

rupture  of,  535 

papillomatous,  509 

simple,  488 

— —  with  ciliated  epithe- 
lium, 491 

dermoids,  492,  495,  502 

suppurating,  535 

embryoma,  492,  495,  502 

— — malignant,  505 

endothelioma,  523 


INDEX 


683 


Ovarian  fibroids,  520 

hydatids,  668 

hydrocele,  607 

ligament,  fibroids  of,  177 

mammse,  498 

papillomatous  cysts,  509 

sarcoma,  522 

teeth,  553 

teratoma,  492,  495,  502 

• tumour  (solid),  8 

axial  rotation  of,  529 

necrosis  of,  532 


Pachydermatocele,  138 

Painful  subcutaneous  tubercle,  130 

Palate,  adenoma  of,  92 

carcinoma  of,  322 

sarcoma  of,  92 

teratoma  of,  435 

Pancreas,  carcinoma  of,  355 

cysts  of,  571 

hydatids  of,  665 

Papilloma,  235 

cutaneous,  235 

intracystic,  238 

of  bladder,  238 

of  choroid  plexus,  241 

of  endometrium,  375 

of  Fallopian  tube,  398 

of  larynx,  237 

of  ovarian  cysts,  509 

of  renal  pelvis,  239 

of  uterus,  375 

villous,  238 

Parasitic  foetus,  422,  544 

theory  of  cancer,  278 

Parathyroid  bodies,  316 

tumours,  6 

Paroophoron,  486 
Parovarian  cysts,  514 
Parovarium  (epoophoron),  487 
Patella,  sarcoma  of,  88 
Pelvis,  chondroma  of,  28 
Penis,  carcinoma  of,  366 

■  torsion  of,  578 

warts  of,  235 

Perirenal  sarcoma,   101 

Perithelioma,  405,  410 

Peritoneal  infection  in  carcinoma,  265 

Permeation  in  carcinoma,   267 

Pharyngocele,  612 

Pliarynx,  carcinoma  of,  322 

cysts  of,  612 

diverticula  of,  612 

imperforate,  613 

pouches  of,  612,  614 

teratoma  of,  435 

Pigmented  nodes,  114 


Pigmented  tumoiirs,  110 

warts,   115 

Pinna,  dermoids  of,  483 

fistulse  of,  482 

sebaceous  cysts  of,  484 

Pituitary  body,  317 
Plexiform  angeioma,   159 

neuroma,  134,  140 

Plimmer's  bodies,  282 
Polypi,  nasal,  59 

uterine,  374 

Port-wine  stains,  156 
Postanal  dimple,  444 

gut,  437 

Postrectal  teratoma,  438 
Pouchj  interdigital,  445 

pharyngeal,  612,  614 

Rathke  s,  612 

Precancerous  conditions,  258 
Pregnancy  and   carcinoma   of   cervix 
uteri,  388 

and  fibroids,   198 

Prostate,  carcinoma  of,  269,  365 

sarcoma  of,  95 

Psammoma,  410 

of  cerebral  membranes,  410 

of  spinal  membranes,  413 

Pseudo-cysts,  611 

connected  with  Fallopian  tube, 

627 
Pyometra,  383,  564 
Pyonephrosis,  564,  585 

Racemose  sarcoma  of  cervix  uteri,  56 

Radicular  odontoma,  218 

Radium  treatment  of  carcinoma,  288 

of  naevi,   161 

of  rodent  ulcer,  312 

Radius,  sarcoma  of,  86 
Ranula,  570 

pancreatic,  571 

Rectum,  adenoma  of,  249 

carcinoma  of,  336,  342 

dermoids  of,   437 

polypi  of,-  249 

teratoma  of,  437,  440 

Recurring  fibroids,  58 

Red  degeneration  of  fibroids,  183,  201 

Renal  {see  Kidney) 

"  Rests  "  in  carcinoma,  275 

Retained  testis,  malignant  disease  of, 

548 
Rete  mirabile,  186 
Retention-cysts,  563 
Retina,  glioma  of,   151 
Retroperitoneal  sarcoma,  57 
Rhabdo-myoma,  55 
Ribs,  sarcoma  of,  88 


684 


INDEX 


Rodent  ulcer,  311 

Round-celled  sarcoma,  52 
Round  ligament,  fibroids  of,  177 
Rudiment,     embryonic,     in     ovarian 
dermoids,  503 


Sacro-coccygeal  tumour,  438 
Sacrum,  dermoids  of,  429 
Salivary  glands,  calculus  of,  570 

chondrifying    tumour    of, 

405 

cysts  of,  570 

endothelioma  of,  405 

mixed  tumour  of,  405 

sarcoma  of,  405 

Sarcoma,  52 

adeno-,  248 

angeio-,  410 

blood-supply  of,  62 

burrowing  tendencies  of,  66 

calcification  of,  69 

degeneration  of,  69 

dissemination  of,  63 

distribution  of,  69 

grape-like  (racemose),  56 

— —  histology  of,  52 

infiltration  of,  64 

lympho-,  53,  547 

melanotic,   112 

myo-,  55 

of  alimentary  canal,  72 

of  bone,  77 

of  breast,  75 

of  bursas,  71 

of  feet,  88 

of  femur,  78 

of  gum,  90 

of  hands,  88 

of  intestine,  73 

of  jaw,  89 

of  kidney,  96,   101 

of  mamma,  75 

of  miiscles,  70 

of  nasal  septum,  89 

of  naso-pharynx,  89 

of  nerves,  70,  134 

of  optic  nerve,   150 

of  ovary,  522 

of  paired  viscera,   100 

of  palate,  92 

of  patella,  88 

of  prostate,  95 

of  radius,  86 

of  ribs,  88 

of  salivary  glands,  405 

of  scapula,  86 

of  skull,  88 

of  sternum,  88 


Sarcoma  of  stomach,  73 

of  synovial  membrane,  70 

of  testicle,  547 

of  tibia,  83 

— " —  of  ulna,  86 

of  uterus,  56 

of  vagina,  74 

of  vermiform  appendix,  73 

of  vertebrae,  92 

perirenal,   101 

racemose,  56 

relation  of,  to  veins,  67 

retroperitoneal,  57 

round-celled,  52 

secondary  changes  in,  69 

deposits  of,  63 

spindle-celled,  53 

subperitoneal,  57 

treatment  of,  75 

Scalp,   dermoids  of,  459 

horns  of,  243 

lipoma  of,   13 

sebaceous   cysts   of,   307 

Scapula,  sarcoma  of,  86 

Scars  of  burns,  carcinoma  of,  256 

Scolices,  653 

Scrotum,  carcinoma  of,  365 

dermoids  of,  445 

horns  of,  243 

hydatids  of,  665 

lipoma  of,   16 

warts  of,  255 

Sebaceous  adenoma,  309 

cysts,  307 

of  pinna,  484 

glands,  carcinoma  of,  311 

horns,  242 

Secondary  carcinoma  of  liver,  347 

• of  lung,  266 

changes  in  fibroids,  180 

in  sarcoma,  69 

deposits  of  carcinoma,  263 

of  sarcoma,  63 

Septate  ileum,  597 
Sinus  (see  Fistula) 
Skin,  endothelioma  of,  410 

of  ovarian  dermoids,  496 

Skull,  sarcoma  of,  88 
Solid  ovarian  tumours,  8 
Soot-wart,  256 
Spermatocele,  550 
Spina  bifida,  638 

complications  of,  646 

masked,  644 

occulta,  644 

treatment  of,  648 

with  cranial  meningocele, 

636 
Spinal  cord,  glioma  of,   153 


INDEX 


685 


Spinal  cord,  lipoma  of,  22 
Spindle-celled  sarcoma,  53 
Spine,  dermoids  of,  443 

hydatids  of,  670 

Spontaneous  fracture,  296 
Squamous-celled  carcinoma,  255 
Sternum,  dermoids  of,  447 

sarcoma  of,  88 

Stomach,  adenoma  of,   249 

carcinoma  of,  330 

leio-myoma  of,  60 

lipoma  of,  17 

myoma  of,  59 

sarcoma  of,  73 

Structure  of  tumours,  2 
Struma  suprarenalis,   103 
Subconjunctival  lipoma,   17 
Subcutaneous  lipoma,  12 
Submucous  fibroids,   169 

lipoma,   17 

Subperitoneal  angeioma,   159 
lipoma,  16 

nsevus,   159 

sarcoma,  67 

Subpleural  lipoma,   17 
Subserous  fibroids,  171,   192 

lipoma,   15 

Subsynovial  lipoma,   18 
Subungual  exostoses,  41 
Sucking-cushion,  19 
Sulcus,  naso-facial,  457 
Supracondyloid  process  of  humerus, 

39 
Sweep's  cancer,  255,  365 
Syncytium,  415 
Synovial  angeioma,   159 

cysts,  620 

sarcoma,   70 

Syrlngo-myelocele,  640 


Tails,  650 

Teeth,  cervical,  in  sheep,  559 

heterotopic,  553 

mastoid,  556 

ovarian,  495,  553 

tympanic,  556 

Telangeiectasis,  156 
Tendons,    ossification    of,,  at    attach- 
ments, 38 
Teratoma,  422 

chorion-epithelioma  and,  420 

■ external,  422 

internal,  433 

intra-abdominal,  433 

intracranial,  435 

intrathoracic,  434 

of  colon,  437 

of  neck,  561 


Teratoma  of  palate,  435 

of  pharynx,  435 

of  testis,  542 

ovarian,  492,  495,  502 

postrectal,  438 

rectal,  437,  440 

Testicle,  adenoma  of,  539 

carcinoma  of,   537 

cystic  disease  of,  538 

dermoids  of,  542 

encysted  hydrocele  of,  550 

■  hydatid  cysts  of,  668 

malignant   disease   in    retained, 

548 

myo-sarcoma     (rhabdo-myoma) 

of,  55 

sarcoma  of,  547 

teratoma  of,  542 

Thorax,  dermoids  of,  434,  447 
Thyro-glossal  duct,  466 
Thyroid,  accessary,  472 

adenoma  of,  249,  313 

carcinoma  of,  315 

cysts  of,  314 

gland  in  ovarian  dermoid,   499 

hydatids  of,  665 

malignancy,  general,   104,  316 

papillomatous  cysts  of,  314 

pyramidal  lobe  of,  472 

Tibia,  sarcoma  of,  83 

Tongue,  angeioma  of,   158 

carcinoma  of,  321 

•  dermoids  of,  467 

ichthyosis  of,  321 

lipoma  of,   19 

lymphangeioma  of,   162 

lympho-sarcoma  of,  53 

Tonsil,  carcinoma  of,   322 

Torsion  of  ovarian  tumours,  529 

of  penis,  578 

Toxin  treatment  of  malignant  disease, 
289 

Tracheal  diverticula,  615 

Tragus,  accessary,  484 

Transformation  of  innocent  into  malig- 
nant tumours,   10 

Treatment  of  tumours  (general),  11 

Tubal  pregnancy  with  fibroids,   203 

Twisted  pedicle  of  fibroids,  193 

of  ovarian  tumours,  529 


Ulcer,  rodent,  311 
Ulna,  sarcoma  of,  86 
Umbilicus,  cysts  of,  594 

tumours  of,  594 

Undescended  testis,  malignant  disease 

in,  548 
Urachus,  cysts  of,  599 


686 


INDEX 


Ureter,  carcinoma  of,  363 

inadequacy  of,  582 

Urethra,  carcinoma  of,  364 

imperforate,  578,  589,  591 

Utero-sacral    ligament,     fibroids     of, 

178 
Uterus,  adenoma  of,  373 

adeno-myoma  of,  375 

carcinoma  of  body  of,  389 

with  fibroids,  395 

of  neck  of,  380 

with  fibroids,  393 

chorion-epithelioma      benignum 

of,  417 
malignum  of,  419 

endothelioma  of,  410 

fibroids  of,  168 

hydatids  of,  666 

myoma  of,  168 

papilloma  of,   375 

sarcoma  of,  56 


Vagina,  carcinoma  of,  369 
— —  cysts  of,  518 

sarcoma  of,  74 

Veins,  relation  of,  to  sarcoma,  67 
Vermiform   appendix,    carcinoma    of, 

337 
cysts  of,  564 


Vermiform     appendix,    hydatids    of, 
665 

sarcoma  of,  73 

Vertebrae,  sarcoma  of,  92 
Villous  papilloma,  238 

of  bladder,  238 

of  choroid  plexus,  241 

of  kidney,  239 

Vitello-intestinal  duct,   cysts   of,   594 
Vulva,  carcinoma  of,  368 


Wandering  goitre,  315 
Wart-horns,  242,  244 
Warts,  234 

•  intracystic,  238 

laryngeal,  237 

of  penis,  235 

soot-,  256 

Warty  ovaries,  514 

Wens,  307,  459 

Withering  cancer,  260,  293 

Wolffian  body,  514,  537,  588 

Woolner's  tip,  485 


Xanthoma,  121 

X-ray  carcinoma,  257 

•  dermatitis,  257 

treatment,  288 


Printed  by  Cassell  and  Company,  Limited,  La  Belle  Sauvage,  London,  B.C. 


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